Provider Demographics
NPI:1437502903
Name:BLAKE, DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 EUREKA SQ
Mailing Address - Street 2:SUITE 151
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-2654
Mailing Address - Country:US
Mailing Address - Phone:650-713-5224
Mailing Address - Fax:
Practice Address - Street 1:80 EUREKA SQ
Practice Address - Street 2:SUITE 151
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-2654
Practice Address - Country:US
Practice Address - Phone:650-713-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 245421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical