MEDICARE: WILLIAM CAMPBELL BLAKE ED.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH3561	FL

General Provider Information

NPI Number	:	1013162825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM CAMPBELL BLAKE ED.D.

Provider Business Mailing Address
First Line	:	605 S FREMONT AVE
Second Line	:	SUITE A
City	:	TAMPA
State	:	FL
Zip	:	33606-2479
Country	:	US
Telephone Number	:	813-417-8552
Fax Number	:	813-258-0600

Provider Business Practice Location Address
First Line	:	605 S FREMONT AVE
Second Line	:	SUITE A
City	:	TAMPA
State	:	FL
Zip	:	33606-2479
Country	:	US
Telephone Number	:	813-417-8552
Fax Number	:	813-258-0600

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2008
Last Update Date	:	11/20/2008

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