Provider Demographics
NPI:1821516436
Name:BLAKE, EMILY ELIZABETH (MS, RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:ELIZABETH
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CROSS ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890
Mailing Address - Country:US
Mailing Address - Phone:617-791-1846
Mailing Address - Fax:
Practice Address - Street 1:107 CROSS ST UNIT A
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890
Practice Address - Country:US
Practice Address - Phone:617-791-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-03
Last Update Date:2017-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4034133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered