Provider Demographics
NPI:1457461246
Name:BLAKE, TERRI LYNN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TERRI
Middle Name:LYNN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:TERRI
Other - Middle Name:L
Other - Last Name:UTTERBACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:815 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1712
Mailing Address - Country:US
Mailing Address - Phone:317-255-8973
Mailing Address - Fax:317-202-0750
Practice Address - Street 1:815 MAIN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1712
Practice Address - Country:US
Practice Address - Phone:317-255-8973
Practice Address - Fax:317-202-0750
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000829A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1010659OtherCIGNA
IN090716OtherMHN
IN000000182780OtherANTHEM