1083632129 NPI number — MS. MARTHA L BLAKE PSYCHOLOGIST, NCPSYT

Table of content: MS. MARTHA L BLAKE PSYCHOLOGIST, NCPSYT (NPI 1083632129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083632129 NPI number — MS. MARTHA L BLAKE PSYCHOLOGIST, NCPSYT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
MARTHA
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PSYCHOLOGIST, NCPSYT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083632129
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
I-5 BETWEEN HWY 217 AND I-205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUALATIN
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97062-9773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-691-6391
Provider Business Mailing Address Fax Number:
503-691-8451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
I-5 BETWEEN HWY 217 AND I-205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-9773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-691-6391
Provider Business Practice Location Address Fax Number:
503-691-8451
Provider Enumeration Date:
07/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 102L00000X , with the licence number:  0003361 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 1824 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0003361 . This is a "LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".