MEDICARE: MS. MONIQUE P BLAKE LMT

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	MA23465	FL

General Provider Information

NPI Number	:	1548492671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MONIQUE P BLAKE LMT

Provider Business Mailing Address
First Line	:	PO BOX 246764
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-0129
Country	:	US
Telephone Number	:	954-558-2002
Fax Number	:	954-797-0331

Provider Business Practice Location Address
First Line	:	1189 SW 26TH AVE
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-3017
Country	:	US
Telephone Number	:	954-558-2002
Fax Number	:	954-797-0331

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

Provider Enumeration Date	:	08/24/2009
Last Update Date	:	08/24/2009

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