=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992683460
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA JEANNE D'ARC ROACH BLAKE LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2025
-----------------------------------------------------
Last Update Date | 08/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 744 MIDDLETOWN RD
-----------------------------------------------------
City | COLCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06415-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-365-5514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 HONEY HILL RD
-----------------------------------------------------
City | EAST HADDAM
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06423-1708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-849-9446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 11503
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------