Provider Demographics
NPI:1962022350
Name:BLAKE, NICOLE E (LCSW, LADC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:JEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 BRACKETT ST APT 3
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-3383
Mailing Address - Country:US
Mailing Address - Phone:603-860-4900
Mailing Address - Fax:
Practice Address - Street 1:40 BRACKETT ST APT 3
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-3383
Practice Address - Country:US
Practice Address - Phone:603-860-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-25
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC7566101YA0400X
NH29051041C0700X
MELC213971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2077079813OtherINDIV NPI