Provider Demographics
NPI:1649365362
Name:BLAKE, STEPHANIE KUULEI (LCSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KUULEI
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:KUULEI
Other - Last Name:SUJETA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:26 W HIDDEN HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-7497
Mailing Address - Country:US
Mailing Address - Phone:801-836-6760
Mailing Address - Fax:
Practice Address - Street 1:26 W HIDDEN HOLLOW DR
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-7497
Practice Address - Country:US
Practice Address - Phone:801-836-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT348922-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker