Provider Demographics
NPI:1962836759
Name:BLAKE, HILLARY S (PSYD)
Entity Type:Individual
Prefix:
First Name:HILLARY
Middle Name:S
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4959
Practice Address - Country:US
Practice Address - Phone:317-944-8162
Practice Address - Fax:317-948-0609
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042875A101YM0800X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN116660020Medicare PIN