Provider Demographics
NPI:1891553012
Name:BLAKE, DEREK J (MS)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:J
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 COUNTRY PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2115
Mailing Address - Country:US
Mailing Address - Phone:941-726-9114
Mailing Address - Fax:
Practice Address - Street 1:3651 COUNTRY PLACE BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2115
Practice Address - Country:US
Practice Address - Phone:941-726-9114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health