Individual
BRENDA REBECCA BLAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3876 BEVERLY AVE NE BLDG G, SALEM, OR 97305-1319
(503) 763-5734
Mailing address
3867 WOLVERINE ST NE BLDG F, SALEM, OR 97305-4266
(503) 763-5734
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
171M00000X
Case Manager/Care Coordinator
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1285243436
—
OR
Enumeration date
07/23/2020
Last updated
06/23/2022
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