Healthcare Provider Details

I. General information

NPI: 1124125927
Provider Name (Legal Business Name): ROBERTA LYNN BLAKE M.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CAMPBELL AVE
WEST HAVEN CT
06516-2770
US

IV. Provider business mailing address

16 WATROUS AVE
BRANFORD CT
06405-3331
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-5711
  • Fax: 203-937-4791
Mailing address:
  • Phone: 203-481-5471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: