Provider Demographics
NPI:1457476301
Name:BLAKE, KRISTINE D (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:D
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Mailing Address - Street 2:9040 JACKSON AVENUE
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98371-1100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CTR 9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:253-968-4146
Practice Address - Fax:253-968-4249
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000073531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical