IndividualActive
John Blake
NPI 1134924475 · Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility · Oshkosh, WI
Provider details
- NPI number
- 1134924475
- Entity type
- Individual
- Primary specialty
- Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityResidential Treatment Facilities
- Sex
- Male
- Sole proprietor
- Yes
- License
- 0017165 (WI)
Specialties & taxonomies
- Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityPrimary320900000XLicense 0017165 (WI)
Residential Treatment Facilities
Practice location
50 Pearl Ave Ste 102
Oshkosh, WI 54901-4811
Phone: (414) 345-7781
Fax: (866) 496-2680
Approximate (ZIP-level) locationGet directions
Mailing address
2844 Montclair Pl
Oshkosh, WI 54904-8944
Additional practice locations (1)
- 2323 Lake Club Dr Ste 301Columbus, OH 43232-3198Phone: (614) 456-4999Fax: (896) 268-0664
Registry dates
- Enumerated
- 2025-02-19
- Last updated
- 2025-02-19
- Certified
- 2025-02-19
Source: CMS NPPES Data Dissemination (June 2026). NPI Central is not affiliated with CMS. Data is provided as-is from the public registry.