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General NPI Number Information
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NPI Number | 1467988360
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Entity Type | Individual
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Provider Name | SHIRLEY R BLAKE M.S.
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Gender | Female
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 24063 HIGHPOINT RD
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City | BRISTOL
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State | VA
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Zip | 24202-4707
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Country | US
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Telephone | 276-971-0079
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Fax | 276-591-5353
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Provider Business Mailing Address
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Address Line | 24063 HIGHPOINT RD
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City | BRISTOL
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State | VA
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Zip | 24202-4707
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Country | US
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Telephone | 276-971-0079
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Fax | 276-591-5353
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171R00000X
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Taxonomy Name | Interpreter
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License Number |
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | PGP-127280
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 405300000X
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Taxonomy Name | Prevention Professional
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License Number | 10,545
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License Number State | VA
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