Provider Demographics
NPI:1114109006
Name:BLAKE, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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 1:2 SARGENT TER
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-2845
Mailing Address - Country:US
Mailing Address - Phone:617-846-0181
Mailing Address - Fax:
Practice Address - Street 1:14 FORDHAM RD
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-3006
Practice Address - Country:US
Practice Address - Phone:617-782-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1001550OtherNHP
MA8411OtherBMC
MA131974Medicaid