Provider Demographics
NPI:1558198655
Name:BLAKE, TERRACE LAMECHIA DIANE (LGPC)
Entity type:Individual
Prefix:
First Name:TERRACE
Middle Name:LAMECHIA DIANE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 FLORAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-9665
Mailing Address - Country:US
Mailing Address - Phone:301-292-2778
Mailing Address - Fax:
Practice Address - Street 1:3102 FLORAL PARK RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-9665
Practice Address - Country:US
Practice Address - Phone:301-292-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-14
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health