Basic Information
| Provider Information | |||||||||
| NPI: | 1356679088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | TOMICA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARPER | ||||||||
| OtherFirstName: | TOMICA | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5000 TOWN CTR | ||||||||
| Address2: | SUITE 2001 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480751110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866850505 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16801 NEWBURGH RD | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489103644 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2009 | ||||||||
| LastUpdateDate: | 11/18/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.