Provider Demographics
NPI:1659889640
Name:BLAKE, NATHANIEL ALLEN (CFBPPC, LCAS)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:ALLEN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:CFBPPC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SAINT MARKS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-9797
Mailing Address - Country:US
Mailing Address - Phone:336-227-5476
Mailing Address - Fax:336-437-1898
Practice Address - Street 1:1230 SAINT MARKS CHURCH RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-9797
Practice Address - Country:US
Practice Address - Phone:336-227-5476
Practice Address - Fax:336-437-1898
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22716101YA0400X
NC116101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)