Provider Demographics
NPI:1215419791
Name:BLAKE, LINDA SUSANNE (LICSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:SUSANNE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19029 US HIGHWAY 19 NORTH, VILLA 22D
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764
Mailing Address - Country:US
Mailing Address - Phone:508-369-0202
Mailing Address - Fax:
Practice Address - Street 1:19029 US HIGHWAY 19 NORTH, VILLA 22D
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764
Practice Address - Country:US
Practice Address - Phone:508-369-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10309141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical