Basic Information
| Provider Information | |||||||||
| NPI: | 1427572478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | MARIAN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5741 SE KING RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972224378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204400982 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 8TH AVE STE D | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970684657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033875449 | ||||||||
| FaxNumber: | 5033426846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2017 | ||||||||
| LastUpdateDate: | 08/01/2017 | ||||||||
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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 | 225100000X | 62268 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.