Provider Demographics
NPI:1598104267
Name:PETERS, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:271 FINCH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-2715
Mailing Address - Country:US
Mailing Address - Phone:203-237-8084
Mailing Address - Fax:203-639-1333
Practice Address - Street 1:271 FINCH AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2715
Practice Address - Country:US
Practice Address - Phone:203-237-8084
Practice Address - Fax:203-639-1333
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1598106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004160941Medicaid
CT260002357C-01560Medicare UPIN