Provider Demographics
NPI:1699703538
Name:BLAKE, PATRICIA J (PHD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:J
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10506 BURT CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2094
Mailing Address - Country:US
Mailing Address - Phone:402-493-4444
Mailing Address - Fax:402-493-1550
Practice Address - Street 1:10506 BURT CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2094
Practice Address - Country:US
Practice Address - Phone:402-493-4444
Practice Address - Fax:402-493-1550
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE526103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE103314OtherVALUE OPTIONS PROVIDER ID
NE08397OtherBC BS OF NE PROVIDER ID
NE103314OtherVALUE OPTIONS PROVIDER ID