Provider Demographics
NPI:1780346650
Name:BLAKE, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 N LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-1661
Mailing Address - Country:US
Mailing Address - Phone:160-370-2352
Mailing Address - Fax:
Practice Address - Street 1:35 N LOWELL RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:NH
Practice Address - Zip Code:03087-1661
Practice Address - Country:US
Practice Address - Phone:160-370-2352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor