Provider Demographics
NPI:1083478150
Name:BLAKE, DAVID WAYNE (MBA, MC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MBA, MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NEW WAVERLY PL STE 100
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7404
Mailing Address - Country:US
Mailing Address - Phone:954-638-9917
Mailing Address - Fax:
Practice Address - Street 1:600 NEW WAVERLY PL STE 100
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7404
Practice Address - Country:US
Practice Address - Phone:954-638-9917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health