Provider Demographics
NPI:1295803328
Name:BLAKE, ANDRA CONIECE (MFTI)
Entity type:Individual
Prefix:MISS
First Name:ANDRA
Middle Name:CONIECE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11702 MENLO AVE
Mailing Address - Street 2:APT. #10
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2585
Mailing Address - Country:US
Mailing Address - Phone:323-981-4322
Mailing Address - Fax:
Practice Address - Street 1:1500 S MCDONNELL AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-5623
Practice Address - Country:US
Practice Address - Phone:323-981-4322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health