Provider Demographics
NPI:1215252630
Name:BLAKE, PAMELA A (PHD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 ANNETTE LN
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1508
Mailing Address - Country:US
Mailing Address - Phone:631-255-5481
Mailing Address - Fax:
Practice Address - Street 1:451 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1357
Practice Address - Country:US
Practice Address - Phone:631-255-5481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018090103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical