MEDICARE: CHARLETHA RENEE 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	1041C0700X	Clinical Social Worker	P020061	NC
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1821652827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLETHA RENEE BLAKE

Provider Business Mailing Address
First Line	:	2328 MILL LN
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-9184
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 MUIRS CHAPEL RD STE 136
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-6173
Country	:	US
Telephone Number	:	336-962-6200
Fax Number	:

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

Provider Enumeration Date	:	04/24/2019
Last Update Date	:	04/14/2026

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