Provider Demographics
NPI:1932944048
Name:BLAKE, CHANDRA (BS, MS)
Entity type:Individual
Prefix:MRS
First Name:CHANDRA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:BS, MS
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
GA101YS0200X, 183700000X, 225C00000X, 374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No183700000XPharmacy Service ProvidersPharmacy Technician
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor