Provider Demographics
NPI:1326040262
Name:ANGOVE, BLAKE (CSW)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:ANGOVE
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 S CHOCOLAY AVE
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-1811
Mailing Address - Country:US
Mailing Address - Phone:248-435-8133
Mailing Address - Fax:
Practice Address - Street 1:6773 W MAPLE RD
Practice Address - Street 2:MAPLEGROVE CENTER
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:248-661-6535
Practice Address - Fax:248-661-6165
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010192521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN13630019Medicare ID - Type Unspecified