MEDICARE: DR. DANIEL BLAKE PH.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	103TC0700X	Clinical Psychologist	6301005841	MI

General Provider Information

NPI Number	:	1992749089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL BLAKE PH.D.

Provider Business Mailing Address
First Line	:	26901 BEAUMONT BLVD STE 3D
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-3849
Country	:	US
Telephone Number	:	947-522-1865
Fax Number	:	947-522-0307

Provider Business Practice Location Address
First Line	:	26789 WOODWARD AVE
Second Line	:
City	:	HUNTINGTON WOODS
State	:	MI
Zip	:	48070-1335
Country	:	US
Telephone Number	:	248-398-3693
Fax Number	:

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	07/22/2022

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