Provider Demographics
NPI:1699140442
Name:DAVIS, BLAKE (LCSW)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 W 11TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-2058
Mailing Address - Country:US
Mailing Address - Phone:512-554-4035
Mailing Address - Fax:
Practice Address - Street 1:813 W 11TH ST STE B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2058
Practice Address - Country:US
Practice Address - Phone:512-554-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX540971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical