Provider Demographics
NPI:1124631494
Name:BLAKE, EYLIN MARGARITA (AMFT)
Entity type:Individual
Prefix:
First Name:EYLIN
Middle Name:MARGARITA
Last Name:BLAKE
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 GUERNEVILLE RD STE 218
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7255
Mailing Address - Country:US
Mailing Address - Phone:707-576-7700
Mailing Address - Fax:
Practice Address - Street 1:1421 GUERNEVILLE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7220
Practice Address - Country:US
Practice Address - Phone:707-576-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8203101YM0800X
CA120639106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health