Provider Demographics
NPI:1598500605
Name:BLAKE, ISRAEL DENNARD
Entity type:Individual
Prefix:MR
First Name:ISRAEL
Middle Name:DENNARD
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2763
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-2763
Mailing Address - Country:US
Mailing Address - Phone:229-228-7775
Mailing Address - Fax:
Practice Address - Street 1:228 AUGUSTA AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-7003
Practice Address - Country:US
Practice Address - Phone:229-228-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP1600X, 374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral