Provider Demographics
NPI:1194856674
Name:BLAKE, MARIN A (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARIN
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 N BOSWORTH AVE
Mailing Address - Street 2:APT 3F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-7013
Mailing Address - Country:US
Mailing Address - Phone:617-501-5851
Mailing Address - Fax:
Practice Address - Street 1:1459 N BOSWORTH AVE
Practice Address - Street 2:APT 3F
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-7013
Practice Address - Country:US
Practice Address - Phone:617-501-5851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist