Provider Demographics
NPI:1326837931
Name:MOSS, BLAKE CARENTON
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:CARENTON
Last Name:MOSS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33010 SE 99TH ST
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-9797
Mailing Address - Country:US
Mailing Address - Phone:425-831-2500
Mailing Address - Fax:
Practice Address - Street 1:4425 ISSAQUAH PINE LAKE RD SE APT I14
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-6247
Practice Address - Country:US
Practice Address - Phone:832-943-7204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61411437101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)