Provider Demographics
NPI:1003827239
Name:BLAKE, JEFFREY (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MONUMENT SQ
Mailing Address - Street 2:#403
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4082
Mailing Address - Country:US
Mailing Address - Phone:207-749-9075
Mailing Address - Fax:
Practice Address - Street 1:22 MONUMENT SQUARE
Practice Address - Street 2:#403
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3914
Practice Address - Country:US
Practice Address - Phone:207-749-9075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC98741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME325620099Medicaid