Provider Demographics
NPI:1831570266
Name:BLAKE, TRINA (SW)
Entity type:Individual
Prefix:
First Name:TRINA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:TRINA
Other - Middle Name:
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:908
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-465-1378
Mailing Address - Fax:304-465-5486
Practice Address - Street 1:908 SCARBRO ROAD
Practice Address - Street 2:
Practice Address - City:SCARBRO
Practice Address - State:WV
Practice Address - Zip Code:25917-0337
Practice Address - Country:US
Practice Address - Phone:304-465-1378
Practice Address - Fax:304-465-5486
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP02943442104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker