Provider Demographics
NPI:1528311735
Name:BLAKE, PHILLIPA (MSW)
Entity type:Individual
Prefix:
First Name:PHILLIPA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 DEWITT ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-2133
Mailing Address - Country:US
Mailing Address - Phone:203-691-2791
Mailing Address - Fax:203-503-6515
Practice Address - Street 1:140 DEWITT ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-2133
Practice Address - Country:US
Practice Address - Phone:203-691-2791
Practice Address - Fax:203-503-6515
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid
CT004235918Medicaid