Provider Demographics
NPI:1578364600
Name:BLARE, KRISTA (MA, LCMHCA)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:BLARE
Suffix:
Gender:
Credentials:MA, LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 S COLLEGE ST UNIT 2415
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4671
Mailing Address - Country:US
Mailing Address - Phone:480-710-2557
Mailing Address - Fax:
Practice Address - Street 1:5970 FAIRVIEW RD STE 126
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-2100
Practice Address - Country:US
Practice Address - Phone:704-762-1361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21210101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty