Provider Demographics
NPI:1114109006
Name:BLAKE, ELIZABETH (MED, LMHC, CAGS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MED, LMHC, CAGS
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:BLAKE-DELVECCHIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:5 TILESTON RD
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152
Mailing Address - Country:US
Mailing Address - Phone:617-240-5907
Mailing Address - Fax:
Practice Address - Street 1:157 GREEN ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2667
Practice Address - Country:US
Practice Address - Phone:617-524-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA10222101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1001550OtherNHP
MA131974Medicaid
MA8411OtherBMC