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General NPI Number Information
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NPI Number | 1962022350
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Entity Type | Individual
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Provider Name | NICOLE E BLAKE LCSW, LADC
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Gender | Female
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Dates
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Enumeration Date | 04/25/2020
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Last Update Date | 10/30/2023
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Provider Practice Location Address
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Address Line | 40 BRACKETT ST APT 3
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City | WESTBROOK
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State | ME
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Zip | 04092-3383
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Country | US
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Telephone | 603-860-4900
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Fax |
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Provider Business Mailing Address
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Address Line | 40 BRACKETT ST APT 3
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City | WESTBROOK
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State | ME
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Zip | 04092-3383
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Country | US
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Telephone | 603-860-4900
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Fax |
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LC7566
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2905
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License Number State | NH
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LC21397
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License Number State | ME
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