Provider Demographics
NPI:1215521901
Name:BLAKE, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 S RAYMOND AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-1961
Mailing Address - Country:US
Mailing Address - Phone:949-229-1632
Mailing Address - Fax:
Practice Address - Street 1:32 S RAYMOND AVE STE 2
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1961
Practice Address - Country:US
Practice Address - Phone:949-229-1632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist