Basic Information
| Provider Information | |||||||||
| NPI: | 1114909587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | GABRIELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HRYHORCHUK | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | GABRIELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1999 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659701295 | ||||||||
| FaxNumber: | 8653801461 | ||||||||
| Practice Location | |||||||||
| Address1: | 6800 BAUM DR | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659709800 | ||||||||
| FaxNumber: | 8653801461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4432 | TN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.