Healthcare Provider Details

I. General information

NPI: 1730026303
Provider Name (Legal Business Name): TYLER MATTHEW BLAKE PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6667 VERNON WOODS DR STE A14
SANDY SPRINGS GA
30328-3236
US

IV. Provider business mailing address

205 12TH ST NE APT 1703
ATLANTA GA
30309-4763
US

V. Phone/Fax

Practice location:
  • Phone: 404-425-9494
  • Fax: 404-549-2877
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016952
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: