Provider Demographics
NPI:1609536903
Name:BLAKE, KRISTINE (LACMH, NCC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LACMH, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 S ANTLERS PL
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-2784
Mailing Address - Country:US
Mailing Address - Phone:302-442-8359
Mailing Address - Fax:
Practice Address - Street 1:256 CHAPMAN RD STE 201
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-5415
Practice Address - Country:US
Practice Address - Phone:302-292-1334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health