Provider Demographics
NPI:1184197154
Name:BLAKE, CORAL LYNN (MSCP)
Entity Type:Individual
Prefix:
First Name:CORAL
Middle Name:LYNN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35054 WHISPERING OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33523-9415
Mailing Address - Country:US
Mailing Address - Phone:172-477-7733
Mailing Address - Fax:
Practice Address - Street 1:35054 WHISPERING OAKS BLVD
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33523-9415
Practice Address - Country:US
Practice Address - Phone:724-777-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health