Provider Demographics
NPI:1336129121
Name:BLAKE, KRISTIN RACHEL (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:RACHEL
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 15762
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367
Mailing Address - Country:US
Mailing Address - Phone:01181614-033-2190
Mailing Address - Fax:
Practice Address - Street 1:PSC 482 BOX 1600
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96367
Practice Address - Country:US
Practice Address - Phone:01181611-734-2747
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19550235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist