Individual
JUSTIN LARON BLAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
2393 BOULDER CHASE DR, ELLENWOOD, GA 30294-1687
(305) 972-7007
Mailing address
2393 BOULDER CHASE DR, ELLENWOOD, GA 30294-1687
(305) 972-7007
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
CSW007974
GA
1041C0700X
Clinical Social Worker
Primary
SW17317
FL
Other
Enumeration date
09/15/2022
Last updated
09/15/2022
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