Healthcare Provider Details

I. General information

NPI: 1659889640
Provider Name (Legal Business Name): NATHANIEL ALLEN BLAKE CFBPPC, LCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 SAINT MARKS CHURCH RD
BURLINGTON NC
27215-9797
US

IV. Provider business mailing address

1230 SAINT MARKS CHURCH RD
BURLINGTON NC
27215-9797
US

V. Phone/Fax

Practice location:
  • Phone: 336-227-5476
  • Fax: 336-437-1898
Mailing address:
  • Phone: 336-227-5476
  • Fax: 336-437-1898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22716
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number116
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: