Provider Demographics
NPI:1881639771
Name:BLAKE, BONNIE JEAN (MA LMHC ,MHP, GMHS)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:JEAN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MA LMHC ,MHP, GMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-2632
Mailing Address - Country:US
Mailing Address - Phone:360-862-1432
Mailing Address - Fax:
Practice Address - Street 1:221 AVENUE B
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2840
Practice Address - Country:US
Practice Address - Phone:425-349-7259
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00003648101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health