Provider Demographics
NPI:1053596569
Name:BLAKE, GINA RENEE (PT)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:RENEE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4754 MARTIN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3507
Mailing Address - Country:US
Mailing Address - Phone:770-967-4377
Mailing Address - Fax:770-967-8077
Practice Address - Street 1:4754 MARTIN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-3507
Practice Address - Country:US
Practice Address - Phone:770-967-4377
Practice Address - Fax:770-967-8077
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11816396OtherCAQH
GA20265I4817OtherMEDICARE PTAN
GA11816396OtherCAQH
GA20265I4817OtherMEDICARE PTAN