Individual
MRS. GINA RENEE BLAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
P.T.
Contact information
Practice address
4754 MARTIN RD, SUITE 200, FLOWERY BRANCH, GA 30542-3507
(770) 967-4377
(770) 967-8077
Mailing address
4754 MARTIN RD, SUITE 200, FLOWERY BRANCH, GA 30542-3507
(770) 967-4377
(770) 967-8077
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
7434
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11816396
CAQH
GA
01
—
20265I4817
MEDICARE PTAN
GA
Enumeration date
01/03/2008
Last updated
12/12/2011
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