Provider Demographics
NPI:1659911428
Name:BLAKE, THOMAS JAMES
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 W SIESTA WAY
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-4232
Mailing Address - Country:US
Mailing Address - Phone:602-799-0424
Mailing Address - Fax:
Practice Address - Street 1:PHOENIX VA HEALTH CARE SYSTEM
Practice Address - Street 2:650 E INDIAN SCHOOL ROAD
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker