Provider Demographics
NPI:1053292870
Name:FARNWORTH, BLAKE ASHLEY
Entity type:Individual
Prefix:MS
First Name:BLAKE
Middle Name:ASHLEY
Last Name:FARNWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BLAKE
Other - Middle Name:ASHLEY
Other - Last Name:WIEGAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250B ROUTE 25A
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-2106
Practice Address - Country:US
Practice Address - Phone:631-291-1570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty