Healthcare Provider Details

I. General information

NPI: 1043948060
Provider Name (Legal Business Name): MICHAEL BLAKE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 POLO PKWY
MIDLOTHIAN VA
23113-1453
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 804-794-7587
  • Fax: 804-794-4560
Mailing address:
  • Phone: 630-575-6200
  • Fax: 410-648-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305215230
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: