Provider Demographics
NPI:1780450114
Name:BLAKE, SHAWNTAE MONIQUE
Entity type:Individual
Prefix:
First Name:SHAWNTAE
Middle Name:MONIQUE
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 1:514 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-3950
Mailing Address - Country:US
Mailing Address - Phone:240-356-3640
Mailing Address - Fax:
Practice Address - Street 1:100 E MAIN ST STE 502
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5079
Practice Address - Country:US
Practice Address - Phone:667-281-0094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14526101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional