Provider Demographics
NPI:1780273979
Name:BLAKE, CELENA L (RBT)
Entity type:Individual
Prefix:
First Name:CELENA
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 GLENCREST LN STE A
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5145
Mailing Address - Country:US
Mailing Address - Phone:903-686-9009
Mailing Address - Fax:
Practice Address - Street 1:701 GLENCREST LN STE A
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5145
Practice Address - Country:US
Practice Address - Phone:903-686-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-20-147523106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician