Healthcare Provider Details

I. General information

NPI: 1235125857
Provider Name (Legal Business Name): MICHELLE L BLAKE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 EWALD AVE SE
SALEM OR
97302-3811
US

IV. Provider business mailing address

580 EWALD AVE SE
SALEM OR
97302-3811
US

V. Phone/Fax

Practice location:
  • Phone: 503-391-1092
  • Fax: 503-363-7424
Mailing address:
  • Phone: 503-391-1092
  • Fax: 503-363-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4657
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: