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General NPI Number Information
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NPI Number | 1861921199
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Entity Type | Organization
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Legal Business Name | TAKE AIM PSYCHOTHERAPY
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Dates
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Enumeration Date | 06/09/2017
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Last Update Date | 06/09/2017
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Provider Practice Location Address
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Address Line | 741 S BENEVA RD
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City | SARASOTA
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State | FL
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Zip | 34232-2411
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Country | US
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Telephone | 941-387-4070
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Fax | 941-922-4742
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Provider Business Mailing Address
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Address Line | PO BOX 15342
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City | SARASOTA
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State | FL
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Zip | 34277-1342
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Country | US
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Telephone | 941-387-4070
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Fax | 941-922-4742
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Authorized Official
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Title or Position | OWNER
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Name | WAYNE S BLAKE
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Credential | DO
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Telephone | 941-387-4070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | OS10255
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License Number State | FL
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