Provider Demographics
NPI:1992170492
Name:TOWE, BLAKE (LICSW)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:TOWE
Suffix:
Gender:M
Credentials:LICSW
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 988
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35602-0988
Mailing Address - Country:US
Mailing Address - Phone:256-341-0811
Mailing Address - Fax:
Practice Address - Street 1:475 PROVIDENCE MAIN ST NW STE 401
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-4818
Practice Address - Country:US
Practice Address - Phone:256-341-0811
Practice Address - Fax:256-341-9358
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4848C101YM0800X
1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL590000025Medicaid