Provider Demographics
NPI:1255708970
Name:BLAKE, TIFFANY G (LCSW)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:G
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 W ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-5648
Mailing Address - Country:US
Mailing Address - Phone:336-736-0455
Mailing Address - Fax:336-628-0111
Practice Address - Street 1:131 W ACADEMY ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5648
Practice Address - Country:US
Practice Address - Phone:336-736-0455
Practice Address - Fax:336-628-0111
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0103731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical