Provider Demographics
NPI:1952399339
Name:POE, BLAKE M (LCPC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:M
Last Name:POE
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 E MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3051
Mailing Address - Country:US
Mailing Address - Phone:208-667-3515
Mailing Address - Fax:208-667-1304
Practice Address - Street 1:408 E MONTANA AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3051
Practice Address - Country:US
Practice Address - Phone:208-667-3515
Practice Address - Fax:208-667-1304
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC3277101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional