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General NPI Number Information
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NPI Number | 1932675766
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Entity Type | Individual
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Provider Name | BLAKE PONIST OT
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Gender | Male
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Dates
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Enumeration Date | 10/19/2018
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Last Update Date | 10/21/2024
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Provider Practice Location Address
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Address Line | 801 CORPORATE CENTRE DR
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City | O FALLON
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State | MO
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Zip | 63368-8685
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Country | US
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Telephone | 636-851-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 600 OAKMONT LN STE 600C
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City | WESTMONT
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State | IL
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Zip | 60559-5548
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Country | US
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Telephone | 630-575-6250
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 31006729A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 2024012844
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License Number State | MO
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