Provider Demographics
NPI:1033122643
Name:BLAKE, DANA J (ACSW)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:J
Last Name:BLAKE
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:517-676-9788
Mailing Address - Fax:517-676-3438
Practice Address - Street 1:3960 PATIENT CARE WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4275
Practice Address - Country:US
Practice Address - Phone:517-882-3732
Practice Address - Fax:517-882-3633
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801064925104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N83250Medicare ID - Type UnspecifiedMCR