Provider Demographics
NPI:1083632129
Name:BLAKE, MARTHA L (PSYCHOLOGIST, NCPSYT)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PSYCHOLOGIST, NCPSYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:I-5 BETWEEN HWY 217 AND I-205
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9773
Mailing Address - Country:US
Mailing Address - Phone:503-691-6391
Mailing Address - Fax:503-691-8451
Practice Address - Street 1:I-5 BETWEEN HWY 217 AND I-205
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9773
Practice Address - Country:US
Practice Address - Phone:503-691-6391
Practice Address - Fax:503-691-8451
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0003361102L00000X
OR1824103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0003361OtherLICENSE