Provider Demographics
NPI:1154804441
Name:BLAKE, DEBORAH ANN
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN
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 1:603 N MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1446
Mailing Address - Country:US
Mailing Address - Phone:815-382-3994
Mailing Address - Fax:
Practice Address - Street 1:1501 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-4649
Practice Address - Country:US
Practice Address - Phone:815-382-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst