| NPI | 1083337919 |
|---|---|
| Former Name | TIFFANY ANN BLAKE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 19791-130) |
| Enumeration Date | 2022-09-26 |
| Last Update Date | 2023-04-19 |