Provider Demographics
NPI:1225191745
Name:BLAKE, DORENE G (MA MFT)
Entity Type:Individual
Prefix:MS
First Name:DORENE
Middle Name:G
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 JADE ST
Mailing Address - Street 2:#31
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010
Mailing Address - Country:US
Mailing Address - Phone:831-476-2433
Mailing Address - Fax:831-476-2433
Practice Address - Street 1:820 BAY AVENUE
Practice Address - Street 2:SUITE 132
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010
Practice Address - Country:US
Practice Address - Phone:831-475-1615
Practice Address - Fax:831-476-2433
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT27688106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist