Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003044066 |
---|---|
Provider Name | Timothy Carl Blake |
First Address | Concord, NC 28025-1831 |
Second Address | Winston Salem, NC 27101-4206 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2009 |
Last Update Date | 29/06/2009 |