Provider Demographics
NPI:1225361231
Name:BLAKE, MARCIA T (LPC)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:T
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 1:7320 PARKRIDGE BLVD APT 67
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-8349
Mailing Address - Country:US
Mailing Address - Phone:616-558-9343
Mailing Address - Fax:
Practice Address - Street 1:7320 PARKRIDGE BLVD APT 67
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-8349
Practice Address - Country:US
Practice Address - Phone:616-558-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011350101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health