Provider Demographics
NPI:1538752282
Name:BLUE, TANEKA M (OTD, OTR/L, CAPS)
Entity type:Individual
Prefix:
First Name:TANEKA
Middle Name:M
Last Name:BLUE
Suffix:
Gender:F
Credentials:OTD, OTR/L, CAPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 VILLAGE FOUNTAIN PL
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-3075
Mailing Address - Country:US
Mailing Address - Phone:850-321-6993
Mailing Address - Fax:
Practice Address - Street 1:5025 VILLAGE FOUNTAIN PL
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-3075
Practice Address - Country:US
Practice Address - Phone:850-321-6993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-13
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty