Provider Demographics
NPI:1003315615
Name:BLAKE, AMY JO
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6528 MCGRAW GAP RD
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:VA
Mailing Address - Zip Code:24445-2522
Mailing Address - Country:US
Mailing Address - Phone:540-691-5387
Mailing Address - Fax:
Practice Address - Street 1:1200 STERRETT RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:VA
Practice Address - Zip Code:24435-2629
Practice Address - Country:US
Practice Address - Phone:434-485-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician