Provider Demographics
NPI:1770096448
Name:BLAKE, MARCUS EPP
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:EPP
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5321 HILL AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102-8529
Mailing Address - Country:US
Mailing Address - Phone:910-987-9039
Mailing Address - Fax:
Practice Address - Street 1:418 CENTER ST
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1712
Practice Address - Country:US
Practice Address - Phone:740-776-2758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator