Healthcare Provider Details

I. General information

NPI: 1144133547
Provider Name (Legal Business Name): FABIANNE BLAKE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 LYMAN PL APT 4B
BRONX NY
10459-1773
US

IV. Provider business mailing address

1360 LYMAN PL APT 4B
BRONX NY
10459-1773
US

V. Phone/Fax

Practice location:
  • Phone: 302-544-2642
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: FABIANNE BLAKE
Title or Position: DR
Credential: PSYD
Phone: 302-544-2642