Provider Demographics
NPI:1558302430
Name:BLAKE, LAURA MICHELE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MICHELE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:MICHELE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:4607 MACCORKLE AVE SW
Mailing Address - Street 2:SUITE 305
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1364
Mailing Address - Country:US
Mailing Address - Phone:304-767-7820
Mailing Address - Fax:304-767-7829
Practice Address - Street 1:4607 MACCORKLE AVE SW
Practice Address - Street 2:SUITE 305
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-767-7820
Practice Address - Fax:304-767-7829
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1590101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional