Healthcare Provider Details

I. General information

NPI: 1033873609
Provider Name (Legal Business Name): SYREETA L BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LOOP ST
CLINTON NC
28328-4062
US

IV. Provider business mailing address

118 JACOBS RIDGE DR
GOLDSBORO NC
27534-7395
US

V. Phone/Fax

Practice location:
  • Phone: 919-596-2221
  • Fax: 919-587-0007
Mailing address:
  • Phone: 850-621-0051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP016937
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: