Provider Demographics
NPI:1760687453
Name:BLAKE, TINA MARIE (LMFT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 CENTRE AVE BLDG E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1887
Mailing Address - Country:US
Mailing Address - Phone:970-224-2080
Mailing Address - Fax:
Practice Address - Street 1:1024 CENTRE AVE BLDG E
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1887
Practice Address - Country:US
Practice Address - Phone:970-224-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO489106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist