MEDICARE: DR. TESSIE BLAKE PSY.D., L.P.

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1104183326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TESSIE BLAKE PSY.D., L.P.

Provider Business Mailing Address
First Line	:	1104 W RIVER RD
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-2723
Country	:	US
Telephone Number	:	218-844-6853
Fax Number	:

Provider Business Practice Location Address
First Line	:	1104 W RIVER RD
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-2723
Country	:	US
Telephone Number	:	218-844-6853
Fax Number	:

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

Provider Enumeration Date	:	04/12/2012
Last Update Date	:	02/22/2016

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