Provider Demographics
NPI:1609437227
Name:BLAKE, ADAM GARY (LCSW)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:GARY
Last Name:BLAKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 PRINCESS RD STE 206
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2322
Mailing Address - Country:US
Mailing Address - Phone:609-482-3701
Mailing Address - Fax:609-482-3702
Practice Address - Street 1:4 PRINCESS RD STE 206
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2322
Practice Address - Country:US
Practice Address - Phone:609-482-3701
Practice Address - Fax:609-482-3702
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC058698001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SC05869800OtherLICENSED CLINICAL SOCIAL WORKER