Provider Demographics
NPI:1679896724
Name:BLAKE, CRYSTAL S (PC)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:S
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 ROSEDALE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44112-3010
Mailing Address - Country:US
Mailing Address - Phone:216-533-8846
Mailing Address - Fax:
Practice Address - Street 1:3413 ROSEDALE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44112-3010
Practice Address - Country:US
Practice Address - Phone:216-533-8846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0501154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health