Provider Demographics
NPI:1114909587
Name:BLAKE, PATRICIA GABRIELLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:GABRIELLE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:PATRICIA
Other - Middle Name:GABRIELLE
Other - Last Name:HRYHORCHUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1999
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37777
Mailing Address - Country:US
Mailing Address - Phone:865-970-1295
Mailing Address - Fax:865-380-1461
Practice Address - Street 1:6800 BAUM DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919
Practice Address - Country:US
Practice Address - Phone:865-970-9800
Practice Address - Fax:865-380-1461
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3926855Medicare ID - Type Unspecified