Provider Demographics
NPI:1598478307
Name:BLAKE, GRACYN ALEXIS
Entity Type:Individual
Prefix:
First Name:GRACYN
Middle Name:ALEXIS
Last Name: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 1:268 VETERANS PKWY STE J
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-6432
Mailing Address - Country:US
Mailing Address - Phone:615-598-6182
Mailing Address - Fax:
Practice Address - Street 1:268 VETERANS PKWY STE J
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-6432
Practice Address - Country:US
Practice Address - Phone:629-207-6370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician