Martha L Blake, PSYCHOLOGIST, NCPSYT
Individual provider Active NPI Psychologist · Tualatin, OR
NPI 1083632129 · NPPES record last updated Dec 16, 2013
Key facts
- NPI
- 1083632129
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Psychologist 103T00000X
- License
- 1824 (OR)
- Practice address
- I-5 Between Hwy 217 and I-205
Tualatin, OR 97062-9773 - Phone
- (503) 691-6391
- Fax
- (503) 691-8451
- NPI assigned
- Jul 17, 2006
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Apr 1, 2016 through Apr 1, 2028
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1824 | OR | MD | Internist Chiropractor |
| 0003361 | NY | MD | Renal Nutrition Registered Dietitian |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychoanalyst | 102L00000X | 0003361 | NY | |
| Psychologist | 103T00000X | 1824 | OR | Yes |
Addresses
Primary practice location
I-5 Between Hwy 217 and I-205
Tualatin, OR 97062-9773
Mailing address
I-5 Between Hwy 217 and I-205
Tualatin, OR 97062-9773
Phone (503) 691-6391
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0003361 | Other | NY | LICENSE |
Other providers in Tualatin, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 16, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Opt Out Affidavits (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.