Basic Information
| Provider Information | |||||||||
| NPI: | 1326379637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | GRIFFIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSMFT LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 S MISSION ST | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092938367 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 ORONDO AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096626000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2010 | ||||||||
| LastUpdateDate: | 07/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | RC00046002 | WA | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | CG60121736 | WA | N | Behavioral Health & Social Service Providers | Counselor | 106H00000X | 201619 | TX | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | LF60173194 | WA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 12043 | 05 | WA | MEDICAID |