Provider Demographics
NPI:1578361333
Name:BLAKE, MICHAEL
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:BLAKE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CART PATH LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-8250
Mailing Address - Country:US
Mailing Address - Phone:617-470-0244
Mailing Address - Fax:
Practice Address - Street 1:388 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-3534
Practice Address - Country:US
Practice Address - Phone:781-472-4049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health