Provider Demographics
NPI:1114367943
Name:BLAKE, ELEESA (MA, LMHC, SUDPT)
Entity Type:Individual
Prefix:
First Name:ELEESA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MA, LMHC, SUDPT
Other - Prefix:
Other - First Name:ELEESA
Other - Middle Name:
Other - Last Name:FLUCKIGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:708 BROADWAY
Mailing Address - Street 2:#170
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3778
Mailing Address - Country:US
Mailing Address - Phone:206-231-5705
Mailing Address - Fax:
Practice Address - Street 1:10001 17TH PL S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98168-1615
Practice Address - Country:US
Practice Address - Phone:303-345-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WACO61062591101YA0400X
WALH61173069101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)