Provider Demographics
NPI:1013162825
Name:BLAKE, WILLIAM CAMPBELL (EDD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CAMPBELL
Last Name:BLAKE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 S FREMONT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2479
Mailing Address - Country:US
Mailing Address - Phone:813-417-8552
Mailing Address - Fax:813-258-0600
Practice Address - Street 1:605 S FREMONT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2479
Practice Address - Country:US
Practice Address - Phone:813-417-8552
Practice Address - Fax:813-258-0600
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3561101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health