Provider Demographics
NPI:1265086912
Name:BLAKE, MEGHAN
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 BOAT CLUB RD STE 106
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7020
Mailing Address - Country:US
Mailing Address - Phone:817-238-0106
Mailing Address - Fax:
Practice Address - Street 1:4516 BOAT CLUB RD STE 106
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7020
Practice Address - Country:US
Practice Address - Phone:817-238-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2024-03-12
Deactivation Date:2024-03-05
Deactivation Code:
Reactivation Date:2024-03-12
Provider Licenses
StateLicense IDTaxonomies
TX89900101Y00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician