Healthcare Provider Details

I. General information

NPI: 1730461369
Provider Name (Legal Business Name): KING BLAKE L.C.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 E NORTH AVE
BALTIMORE MD
21213-1405
US

IV. Provider business mailing address

1317 E NORTH AVE
BALTIMORE MD
21213-1405
US

V. Phone/Fax

Practice location:
  • Phone: 410-240-0785
  • Fax:
Mailing address:
  • Phone: 410-240-0785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberLC4136
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: