Provider Demographics
NPI:1447077375
Name:BLAKE, TREVOR GLENN (RADT)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:GLENN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7560 FAIRLANE AVE
Mailing Address - Street 2:
Mailing Address - City:WINTON
Mailing Address - State:CA
Mailing Address - Zip Code:95388-9376
Mailing Address - Country:US
Mailing Address - Phone:209-349-1311
Mailing Address - Fax:
Practice Address - Street 1:301 E 13TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6211
Practice Address - Country:US
Practice Address - Phone:209-381-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1573850824101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)