Provider Demographics
NPI:1467988360
Name:BLAKE, SHIRLEY R (MS)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:R
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24063 HIGHPOINT RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4707
Mailing Address - Country:US
Mailing Address - Phone:276-971-0079
Mailing Address - Fax:276-591-5353
Practice Address - Street 1:24063 HIGHPOINT RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-4707
Practice Address - Country:US
Practice Address - Phone:276-971-0079
Practice Address - Fax:276-591-5353
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA171R00000X
VAPGP-127280174400000X
VA10,545405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171R00000XOther Service ProvidersInterpreter
No405300000XOther Service ProvidersPrevention Professional