Provider Demographics
NPI:1053186536
Name:BLAKE DIRCKSEN DPT PT PLLC
Entity type:Organization
Organization Name:BLAKE DIRCKSEN DPT PT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIRCKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:317-385-8525
Mailing Address - Street 1:348 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-2519
Mailing Address - Country:US
Mailing Address - Phone:317-385-8525
Mailing Address - Fax:
Practice Address - Street 1:348 S 6TH ST
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2519
Practice Address - Country:US
Practice Address - Phone:317-385-8525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLAKE DIRCKSEN DPT PT PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty