Provider Demographics
NPI:1548507882
Name:BLAKE, MELISSA (ACSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2429
Mailing Address - Country:US
Mailing Address - Phone:310-566-1470
Mailing Address - Fax:
Practice Address - Street 1:2825 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2429
Practice Address - Country:US
Practice Address - Phone:310-566-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 31925101YM0800X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW 31925OtherBOARD OF BEHAVIORAL SCIENCES