Healthcare Provider Details

I. General information

NPI: 1114109006
Provider Name (Legal Business Name): ELIZABETH BLAKE M.ED, LMHC, CAGS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH BLAKE-DELVECCHIO LMHC

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 TILESTON RD
WINTHROP MA
02152-2734
US

IV. Provider business mailing address

5 TILESTON RD
WINTHROP MA
02152-2734
US

V. Phone/Fax

Practice location:
  • Phone: 617-240-5907
  • Fax:
Mailing address:
  • Phone: 617-240-5907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10222
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: