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General NPI Number Information
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NPI Number | 1720280654
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Entity Type | Individual
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Provider Name | HEATHER LEE BLAKE MPT
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Gender | Female
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Dates
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Enumeration Date | 06/04/2007
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Last Update Date | 09/01/2015
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Provider Practice Location Address
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Address Line | 152 S BLOOMINGDALE RD UNIT 101
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1481
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Country | US
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Telephone | 630-893-5534
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Fax | 630-893-5527
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Provider Business Mailing Address
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Address Line | 26806 BASSWOOD CIR
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City | PLAINFIELD
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State | IL
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Zip | 60585-2932
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Country | US
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Telephone | 630-893-5534
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Fax | 630-893-5527
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070.012919
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License Number State | IL
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