Provider Demographics
NPI:1407401185
Name:BLAKE, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
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 1:13322 I ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1111
Mailing Address - Country:US
Mailing Address - Phone:402-230-5861
Mailing Address - Fax:531-200-5808
Practice Address - Street 1:13322 I ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1111
Practice Address - Country:US
Practice Address - Phone:402-230-5861
Practice Address - Fax:531-200-5808
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NE3113101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health