Healthcare Provider Details

I. General information

NPI: 1942675152
Provider Name (Legal Business Name): COURTNEY BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VERMILLION ST
CENTERVILLE SD
57014-2168
US

IV. Provider business mailing address

29468 466TH AVE
CENTERVILLE SD
57014-6308
US

V. Phone/Fax

Practice location:
  • Phone: 605-212-3446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number076277
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0967
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: