Provider Demographics
NPI:1033873609
Name:BLAKE, SYREETA L
Entity Type:Individual
Prefix:
First Name:SYREETA
Middle Name:L
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 1:118 JACOBS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-7395
Mailing Address - Country:US
Mailing Address - Phone:850-621-0051
Mailing Address - Fax:
Practice Address - Street 1:100 LOOP ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-4062
Practice Address - Country:US
Practice Address - Phone:919-596-2221
Practice Address - Fax:919-587-0007
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0169371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical