Provider Demographics
NPI:1568150324
Name:ADOLPH-BLAKE, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:ADOLPH-BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8909 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1219
Mailing Address - Country:US
Mailing Address - Phone:330-310-6112
Mailing Address - Fax:
Practice Address - Street 1:8909 W. 11 MILE RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1219
Practice Address - Country:US
Practice Address - Phone:330-310-6112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI200030671041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool