Provider Demographics
NPI:1770181059
Name:HERD, BLAKE DANIEL (MA, LPA)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:DANIEL
Last Name:HERD
Suffix:
Gender:M
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 HIGHWOODS BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-2051
Mailing Address - Country:US
Mailing Address - Phone:336-272-0855
Mailing Address - Fax:
Practice Address - Street 1:1501 HIGHWOODS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2051
Practice Address - Country:US
Practice Address - Phone:336-272-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5785103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical