Provider Demographics
NPI:1609623768
Name:BLAKE, STEPHANIE (LPC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-2604
Mailing Address - Country:US
Mailing Address - Phone:440-721-8306
Mailing Address - Fax:
Practice Address - Street 1:2217 BENNETT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-2604
Practice Address - Country:US
Practice Address - Phone:440-721-8306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1400506101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health