Provider Demographics
NPI:1144710815
Name:BLAKE, STEPHANIE (ATC/LAT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:AR
Mailing Address - Zip Code:72432-1306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 W FULBRIGHT ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-9000
Practice Address - Country:US
Practice Address - Phone:870-208-5631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT7012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty