Provider Demographics
NPI:1407292915
Name:BLAKE, REBECCA THOMSON
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:THOMSON
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:910-742-9243
Mailing Address - Fax:888-746-1787
Practice Address - Street 1:1213 CULBRETH DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3639
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:888-746-1787
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0095531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical