Provider Demographics
NPI:1861764144
Name:BLAKE, KRISTINA N (OTR/L)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:N
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 COLOR PL STE 101
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-7717
Mailing Address - Country:US
Mailing Address - Phone:352-394-0212
Mailing Address - Fax:352-241-6361
Practice Address - Street 1:1000 COLOR PL STE 101
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-7717
Practice Address - Country:US
Practice Address - Phone:352-394-0212
Practice Address - Fax:352-241-6361
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT15041225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00462440Medicaid