Individual
AMANDA MAE BLAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1 ELIZABETH PL STE NWB40, DAYTON, OH 45417-3445
(937) 401-8672
Mailing address
1628 SPRINGFIELD ST, DAYTON, OH 45403-1430
(937) 802-5440
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
186070
OH
171M00000X
Case Manager/Care Coordinator
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0466273
—
OH
Enumeration date
10/18/2021
Last updated
02/15/2024
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