Provider Demographics
NPI:1548599111
Name:BLAKE, TARA ELISE (MA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ELISE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 PESCARA BLVD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2991
Mailing Address - Country:US
Mailing Address - Phone:530-518-9991
Mailing Address - Fax:
Practice Address - Street 1:142 PESCARA BLVD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2991
Practice Address - Country:US
Practice Address - Phone:530-518-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17555235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist