Provider Demographics
NPI:1154140192
Name:BLAKE, ERIN MICHELLE
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:MICHELLE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4727 BRADLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704
Mailing Address - Country:US
Mailing Address - Phone:304-633-6343
Mailing Address - Fax:
Practice Address - Street 1:4727 BRADLEY ROAD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-1812
Practice Address - Country:US
Practice Address - Phone:304-633-6343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency