Provider Demographics
NPI:1083468953
Name:BLAKE, CALLIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:ELIZABETH
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 1:4819 POE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-4621
Mailing Address - Country:US
Mailing Address - Phone:818-257-9938
Mailing Address - Fax:
Practice Address - Street 1:4774 PARK GRANADA UNIT 8742
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91372-7037
Practice Address - Country:US
Practice Address - Phone:310-853-2489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA145394101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health