Provider Demographics
NPI:1790913952
Name:BLAKE, PAM M
Entity Type:Individual
Prefix:MRS
First Name:PAM
Middle Name:M
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 1:17615 SW 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-5636
Mailing Address - Country:US
Mailing Address - Phone:786-268-2611
Mailing Address - Fax:305-252-2778
Practice Address - Street 1:17615 SW 97TH AVE
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-5636
Practice Address - Country:US
Practice Address - Phone:786-268-2611
Practice Address - Fax:305-252-2778
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker