Provider Demographics
NPI:1720127855
Name:BLAKE, SUSAN D (LPC)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:D
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 MORRIS FARM DR
Mailing Address - Street 2:3B
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-8944
Mailing Address - Country:US
Mailing Address - Phone:336-402-7346
Mailing Address - Fax:
Practice Address - Street 1:3650 MORRIS FARM DR
Practice Address - Street 2:3B
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-8944
Practice Address - Country:US
Practice Address - Phone:336-402-7346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103471Medicaid