Provider Demographics
NPI:1639626294
Name:BLAKE, KAI BERGONDI (MED)
Entity Type:Individual
Prefix:
First Name:KAI
Middle Name:BERGONDI
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 POMFRET RD
Mailing Address - Street 2:
Mailing Address - City:POMFRET
Mailing Address - State:MD
Mailing Address - Zip Code:20675-3218
Mailing Address - Country:US
Mailing Address - Phone:240-412-8260
Mailing Address - Fax:
Practice Address - Street 1:1919 15TH ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020
Practice Address - Country:US
Practice Address - Phone:240-412-8260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC10993888103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool