Provider Demographics
NPI:1336375062
Name:DOTSON-BLAKE, KYLIE PHARES (PHD, LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:KYLIE
Middle Name:PHARES
Last Name:DOTSON-BLAKE
Suffix:
Gender:F
Credentials:PHD, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EAST FIFTH STREET 223A RAGSDALE
Mailing Address - Street 2:EAST CAROLINA UNIVERSITY/COAD DEPT
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-4353
Mailing Address - Country:US
Mailing Address - Phone:252-328-5277
Mailing Address - Fax:
Practice Address - Street 1:EAST FIFTH STREET 223A RAGSDALE
Practice Address - Street 2:EAST CAROLINA UNIVERSITY/COAD DEPT
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-4353
Practice Address - Country:US
Practice Address - Phone:252-328-5277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4986101YP2500X
NC101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool