Healthcare Provider Details

I. General information

NPI: 1306509211
Provider Name (Legal Business Name): AMANDA MAE BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL STE NWB40
DAYTON OH
45417-3445
US

IV. Provider business mailing address

1628 SPRINGFIELD ST
DAYTON OH
45403-1430
US

V. Phone/Fax

Practice location:
  • Phone: 937-401-8672
  • Fax:
Mailing address:
  • Phone: 937-802-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number186070
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: