Provider Demographics
NPI:1083462626
Name:BLAKE, WILLIAM H W (CADC-I, C HT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:H W
Last Name:BLAKE
Suffix:
Gender:U
Credentials:CADC-I, C HT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 E ORANGE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-4726
Mailing Address - Country:US
Mailing Address - Phone:318-664-0742
Mailing Address - Fax:
Practice Address - Street 1:1562 E ORANGE GROVE BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-4726
Practice Address - Country:US
Practice Address - Phone:318-664-0742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI42350424101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)