Provider Demographics
NPI:1548813918
Name:BLAKE, COURTNEY CHRISTINE (LCSW)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:CHRISTINE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ULSTER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12487-5407
Mailing Address - Country:US
Mailing Address - Phone:845-464-7018
Mailing Address - Fax:
Practice Address - Street 1:758 BROADWAY
Practice Address - Street 2:
Practice Address - City:ULSTER PARK
Practice Address - State:NY
Practice Address - Zip Code:12487-5407
Practice Address - Country:US
Practice Address - Phone:845-464-7018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087122-11041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical