Provider Demographics
NPI:1174883045
Name:BLAKE, HEATHER MICHELLE
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MICHELLE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CONGAREE MILL LN
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-5357
Mailing Address - Country:US
Mailing Address - Phone:609-731-0994
Mailing Address - Fax:
Practice Address - Street 1:1311 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6320
Practice Address - Country:US
Practice Address - Phone:803-926-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC4217225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty