Provider Demographics
NPI:1871516104
Name:BLAKE, WILTON E I (DMIN/BCC)
Entity type:Individual
Prefix:DR
First Name:WILTON
Middle Name:E
Last Name:BLAKE
Suffix:I
Gender:M
Credentials:DMIN/BCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 GLENSPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:OH
Mailing Address - Zip Code:45246-2129
Mailing Address - Country:US
Mailing Address - Phone:513-638-8511
Mailing Address - Fax:513-851-8191
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-262-3394
Practice Address - Fax:937-267-5351
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral