MEDICARE: EVETTE BLAKE LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA60108107	WA

General Provider Information

NPI Number	:	1417279795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVETTE BLAKE LMP

Provider Business Mailing Address
First Line	:	929 ECKARD PL
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-6776
Country	:	US
Telephone Number	:	360-477-6358
Fax Number	:

Provider Business Practice Location Address
First Line	:	929 ECKARD PL
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-6776
Country	:	US
Telephone Number	:	360-477-6358
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2010
Last Update Date	:	04/21/2010

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