Provider Demographics
NPI:1417609090
Name:BLAKE, DIA LAQUAN
Entity Type:Individual
Prefix:
First Name:DIA
Middle Name:LAQUAN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 E 96TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-1206
Mailing Address - Country:US
Mailing Address - Phone:216-258-4300
Mailing Address - Fax:
Practice Address - Street 1:398 W BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1369
Practice Address - Country:US
Practice Address - Phone:216-340-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health