Provider Demographics
NPI:1548822000
Name:BLAKE, JANICE (PMHNP)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:S GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-2919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:S GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06073-2919
Practice Address - Country:US
Practice Address - Phone:860-266-7826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8329363L00000X, 363LP0200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics