Provider Demographics
NPI:1275102055
Name:BLAKE, KENDALL (LCSW)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1778 CENTURY BLVD NE STE A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3398
Mailing Address - Country:US
Mailing Address - Phone:202-352-5891
Mailing Address - Fax:
Practice Address - Street 1:1778 CENTURY BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3398
Practice Address - Country:US
Practice Address - Phone:202-352-5891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0070081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical