Provider Demographics
NPI:1134473473
Name:BLAKE, PAMELA (MSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 S CONGRESS AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33406-7670
Mailing Address - Country:US
Mailing Address - Phone:561-653-6292
Mailing Address - Fax:
Practice Address - Street 1:2112 S CONGRESS AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33406-7670
Practice Address - Country:US
Practice Address - Phone:561-653-6292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 6007104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker