Provider Demographics
NPI:1356868236
Name:BLAKE, GWENDOLYN (MA, EDS, LPC)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MA, EDS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08848-1003
Mailing Address - Country:US
Mailing Address - Phone:908-892-0005
Mailing Address - Fax:
Practice Address - Street 1:65 OLD RT. 22
Practice Address - Street 2:SUITE 7B
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809
Practice Address - Country:US
Practice Address - Phone:908-386-2897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00540100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty