Healthcare Provider Details

I. General information

NPI: 1437502903
Provider Name (Legal Business Name): DIANE BLAKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 EUREKA SQ SUITE 151
PACIFICA CA
94044-2654
US

IV. Provider business mailing address

80 EUREKA SQ SUITE 151
PACIFICA CA
94044-2654
US

V. Phone/Fax

Practice location:
  • Phone: 650-713-5224
  • Fax:
Mailing address:
  • Phone: 650-713-5224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 24542
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: