Healthcare Provider Details

I. General information

NPI: 1437094281
Provider Name (Legal Business Name): WHITLEY BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 S TELEGRAPH RD STE 104
BLOOMFIELD HILLS MI
48302-0177
US

IV. Provider business mailing address

1750 S TELEGRAPH RD STE 104
BLOOMFIELD HILLS MI
48302-0177
US

V. Phone/Fax

Practice location:
  • Phone: 248-256-5209
  • Fax: 248-239-1522
Mailing address:
  • Phone: 248-270-5882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6352001204
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: