Provider Demographics
NPI:1548492671
Name:BLAKE, MONIQUE P (LMT)
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:P
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 246764
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-0129
Mailing Address - Country:US
Mailing Address - Phone:954-558-2002
Mailing Address - Fax:954-797-0331
Practice Address - Street 1:1189 SW 26TH AVE
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-3017
Practice Address - Country:US
Practice Address - Phone:954-558-2002
Practice Address - Fax:954-797-0331
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA23465225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist