Provider Demographics
NPI:1790107274
Name:BLAKE, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 COLISEUM CENTRE DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1452
Mailing Address - Country:US
Mailing Address - Phone:704-357-7920
Mailing Address - Fax:704-357-7921
Practice Address - Street 1:2815 COLISEUM CENTRE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1452
Practice Address - Country:US
Practice Address - Phone:704-357-7920
Practice Address - Fax:704-357-7921
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health