Provider Demographics
NPI:1720559107
Name:BLAKE, KYLE ANDREW (LCSW)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ANDREW
Last Name:BLAKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2486
Mailing Address - Street 2:
Mailing Address - City:HELENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:92342-2486
Mailing Address - Country:US
Mailing Address - Phone:760-490-6484
Mailing Address - Fax:
Practice Address - Street 1:10918 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-2151
Practice Address - Country:US
Practice Address - Phone:760-490-6484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW764081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty