Provider Demographics
NPI:1770242588
Name:BLAKE, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:DIEHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1268 RUSSET LN
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27523-8516
Mailing Address - Country:US
Mailing Address - Phone:910-429-4943
Mailing Address - Fax:
Practice Address - Street 1:5121 KINGDOM WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6062
Practice Address - Country:US
Practice Address - Phone:800-442-2762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician