Healthcare Provider Details

I. General information

NPI: 1841813201
Provider Name (Legal Business Name): MISS MICKIA TICRE BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 NW UNIVERSITY BLVD STE 204
PORT ST LUCIE FL
34986-2281
US

IV. Provider business mailing address

540 NW UNIVERSITY BLVD STE 204
PORT ST LUCIE FL
34986-2281
US

V. Phone/Fax

Practice location:
  • Phone: 561-216-5711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH28976
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: