Provider Demographics
NPI:1902002066
Name:BLAKE, DENISE M (LAC)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3012
Mailing Address - Country:US
Mailing Address - Phone:619-232-6220
Mailing Address - Fax:
Practice Address - Street 1:1407 2ND AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3012
Practice Address - Country:US
Practice Address - Phone:619-232-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6562171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist