Provider Demographics
NPI:1639935240
Name:BLAKE, DELLA REA (MED, LADC 1)
Entity Type:Individual
Prefix:
First Name:DELLA
Middle Name:REA
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MED, LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 BARRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01129-1455
Mailing Address - Country:US
Mailing Address - Phone:413-348-3452
Mailing Address - Fax:
Practice Address - Street 1:13 BARRINGTON DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01129
Practice Address - Country:US
Practice Address - Phone:413-348-3452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)