Provider Demographics
NPI:1366612525
Name:RODGERS, BLAKE FRANCIS (MFT MARRIAGE FAMILY)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:FRANCIS
Last Name:RODGERS
Suffix:
Gender:M
Credentials:MFT MARRIAGE FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 5TH AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2928
Mailing Address - Country:US
Mailing Address - Phone:415-454-3336
Mailing Address - Fax:415-454-3941
Practice Address - Street 1:900 5TH AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2928
Practice Address - Country:US
Practice Address - Phone:415-454-3336
Practice Address - Fax:415-454-3941
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMX015584106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist