Provider Demographics
NPI:1124180898
Name:BLAKE, JULIE E (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:E
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-0450
Mailing Address - Country:US
Mailing Address - Phone:304-760-6300
Mailing Address - Fax:304-201-5123
Practice Address - Street 1:179 STATION PLACE WAY
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8747
Practice Address - Country:US
Practice Address - Phone:304-760-6300
Practice Address - Fax:304-201-5123
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-759235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV31150445300OtherWORKERS COMP
WV9400072-000Medicaid
WV1712303OtherBLUE CROSS BLUE SHIELD
WV6147520OtherCIGNA
WV311504453OtherACORDIA