Provider Demographics
NPI:1861876963
Name:BLAKE, MICHAEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 962
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01262-0962
Mailing Address - Country:US
Mailing Address - Phone:413-931-5235
Mailing Address - Fax:
Practice Address - Street 1:25 MAIN ST.
Practice Address - Street 2:OFFICE 322
Practice Address - City:STOCKBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01262-0962
Practice Address - Country:US
Practice Address - Phone:413-931-5235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10144103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist