Provider Demographics
NPI:1922771765
Name:BLAKE, KIMBERLEY (MA, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MA, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-4323
Mailing Address - Country:US
Mailing Address - Phone:203-450-9944
Mailing Address - Fax:
Practice Address - Street 1:140 JOHN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4323
Practice Address - Country:US
Practice Address - Phone:203-450-9944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004945101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional