Basic Information
| Provider Information | |||||||||
| NPI: | 1962137844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALTIZER | ||||||||
| FirstName: | BLAKE | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2982 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PERU | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129722926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185656129 | ||||||||
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| Practice Location | |||||||||
| Address1: | 43490 YUKON DR STE 212 | ||||||||
| Address2: | |||||||||
| City: | ASHBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201477326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037297920 | ||||||||
| FaxNumber: | 7037297923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2022 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305215189 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.