Provider Demographics
NPI:1215394424
Name:BLAKE, KEVIN (PC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-3736
Mailing Address - Country:US
Mailing Address - Phone:216-432-7200
Mailing Address - Fax:216-432-7253
Practice Address - Street 1:4400 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-3734
Practice Address - Country:US
Practice Address - Phone:216-432-7200
Practice Address - Fax:216-432-7253
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1300277101YP2500X
OHE.1800638101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC1300277OtherSTATE LICENSE