Provider Demographics
NPI:1710768577
Name:BLAKE, SCOTT WALTER (SUDPT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:WALTER
Last Name:BLAKE
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15838 104TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-9567
Mailing Address - Country:US
Mailing Address - Phone:585-219-3157
Mailing Address - Fax:
Practice Address - Street 1:235 S 3RD ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2255
Practice Address - Country:US
Practice Address - Phone:360-426-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61479679101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)