Provider Demographics
NPI:1639604655
Name:BLAKE, DOREEN (LPC, CDC1)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPC, CDC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 256
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:733 2ND AVENUE
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752-1453
Practice Address - Country:US
Practice Address - Phone:907-442-7640
Practice Address - Fax:907-442-7749
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK153055101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional