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General NPI Number Information
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NPI Number | 1831918465
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Entity Type | Individual
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Provider Name | BLAKE EDWARD STOUTENBURG
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Gender | Male
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Dates
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Enumeration Date | 10/09/2024
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Last Update Date | 10/20/2025
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Provider Practice Location Address
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Address Line | 580 S SAN VICENTE BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90048-4621
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Country | US
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Telephone | 323-782-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 1231 E 6600 S
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City | MURRAY
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State | UT
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Zip | 84121-2450
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Country | US
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Telephone | 248-326-4050
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Fax |
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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 | 308213
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 3043172-2401
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License Number State | UT
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