MEDICARE: DESTINY MONIQUE BLAKE

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	175T00000X	Peer Specialist	51878390	TX

General Provider Information

NPI Number	:	1588547269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY MONIQUE BLAKE

Provider Business Mailing Address
First Line	:	13611 PERRY RD APT 4105
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-4587
Country	:	US
Telephone Number	:	443-397-6352
Fax Number	:

Provider Business Practice Location Address
First Line	:	13611 PERRY RD APT 4105
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-4587
Country	:	US
Telephone Number	:	443-397-6352
Fax Number	:

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

Provider Enumeration Date	:	07/29/2025
Last Update Date	:	07/29/2025

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Directions to “ DESTINY MONIQUE BLAKE ” Practice Location

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