Provider Demographics
NPI:1457931586
Name:BLAKE, ELIZABETH GRACE (BA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 DON KNOTTS BLVD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-6838
Mailing Address - Country:US
Mailing Address - Phone:304-284-0025
Mailing Address - Fax:304-284-0031
Practice Address - Street 1:53 DON KNOTTS BLVD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-6838
Practice Address - Country:US
Practice Address - Phone:304-284-0025
Practice Address - Fax:304-284-0031
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)