Basic Information
| Provider Information | |||||||||
| NPI: | 1659911428 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5016 W SIESTA WAY | ||||||||
| Address2: | |||||||||
| City: | LAVEEN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853394232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027990424 | ||||||||
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| Practice Location | |||||||||
| Address1: | PHOENIX VA HEALTH CARE SYSTEM | ||||||||
| Address2: | 650 E INDIAN SCHOOL ROAD | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022775551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2020 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.