Provider Demographics
NPI:1194033142
Name:BLAKE, AMALIA C (MSED)
Entity Type:Individual
Prefix:MRS
First Name:AMALIA
Middle Name:C
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 43RD ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2306
Mailing Address - Country:US
Mailing Address - Phone:631-225-7038
Mailing Address - Fax:
Practice Address - Street 1:471 43RD ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2306
Practice Address - Country:US
Practice Address - Phone:631-225-7038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst