Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 115900 | TX |
N | 225XN1300X | Occupational Therapist - Neurorehabilitation | 115900 | TX |
NPI | 1003232240 |
---|---|
Provider Name | Orville Livingstone Blake |
First Address | Helotes, TX 78023-3621 |
Second Address | San Antonio, TX 78229-4404 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2014 |
Last Update Date | 13/03/2014 |