Healthcare Provider Details

I. General information

NPI: 1083632129
Provider Name (Legal Business Name): MARTHA L BLAKE PSYCHOLOGIST, NCPSYT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I-5 BETWEEN HWY 217 AND I-205
TUALATIN OR
97062-9773
US

IV. Provider business mailing address

I-5 BETWEEN HWY 217 AND I-205
TUALATIN OR
97062-9773
US

V. Phone/Fax

Practice location:
  • Phone: 503-691-6391
  • Fax: 503-691-8451
Mailing address:
  • Phone: 503-691-6391
  • Fax: 503-691-8451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number0003361
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1824
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: