Individual
JEFFREY BLAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
22 MONUMENT SQUARE, #403, PORTLAND, ME 04101-3914
(207) 749-9075
Mailing address
22 MONUMENT SQ, #403, PORTLAND, ME 04101-4082
(207) 749-9075
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
LC9874
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
325620099
—
ME
Enumeration date
08/11/2006
Last updated
03/11/2013
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