Individual
LISA JOLENE BLAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4933 S 1500 W STE 200, RIVERDALE, UT 84405-7738
(385) 427-1072
Mailing address
1314 24TH ST, OGDEN, UT 84401-2902
(801) 695-5057
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
6306212-3501
UT
Other
Enumeration date
02/26/2020
Last updated
03/05/2023
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