=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477416949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAKE A DOUGLAS OTR/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2025
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1212 S NAPER BLVD STE 104
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60540-8398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-369-2340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 BUTTERFIELD RD STE 1600
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-1211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------