Provider Demographics
NPI:1457767907
Name:BLAKE, LISA (LIC AC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 HIGH ST # 2
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-0545
Mailing Address - Country:US
Mailing Address - Phone:804-931-8288
Mailing Address - Fax:
Practice Address - Street 1:16 BRADLEE RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3171
Practice Address - Country:US
Practice Address - Phone:781-269-2849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-05
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist