Provider Demographics
NPI:1861921199
Name:TAKE AIM PSYCHOTHERAPY
Entity type:Organization
Organization Name:TAKE AIM PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:941-387-4070
Mailing Address - Street 1:PO BOX 15342
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-1342
Mailing Address - Country:US
Mailing Address - Phone:941-387-4070
Mailing Address - Fax:941-922-4742
Practice Address - Street 1:741 S BENEVA RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-2411
Practice Address - Country:US
Practice Address - Phone:941-387-4070
Practice Address - Fax:941-922-4742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280257100Medicaid
FLOS10255OtherSTATE MEDICAL LICENSE