Provider Demographics
NPI:1265714075
Name:BLAKE, ALISTAIR (LCSW)
Entity type:Individual
Prefix:MR
First Name:ALISTAIR
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 UNIVERSITY PL
Mailing Address - Street 2:SUITE 914
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4527
Mailing Address - Country:US
Mailing Address - Phone:347-878-0403
Mailing Address - Fax:
Practice Address - Street 1:113 UNIVERSITY PL
Practice Address - Street 2:SUITE 914
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4527
Practice Address - Country:US
Practice Address - Phone:347-878-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400121754Medicare PIN