Healthcare Provider Details

I. General information

NPI: 1124631494
Provider Name (Legal Business Name): EYLIN MARGARITA BLAKE AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 GUERNEVILLE RD
SANTA ROSA CA
95403-7220
US

IV. Provider business mailing address

1421 GUERNEVILLE RD STE 218
SANTA ROSA CA
95403-7255
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-7700
  • Fax:
Mailing address:
  • Phone: 707-576-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8203
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number120639
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: