Provider Demographics
NPI:1184396038
Name:BLAKE, MICHELLE (LPC ASSOCIATE)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPC ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9594 S STATE HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:SCURRY
Mailing Address - State:TX
Mailing Address - Zip Code:75158-3146
Mailing Address - Country:US
Mailing Address - Phone:469-212-5552
Mailing Address - Fax:
Practice Address - Street 1:9594 S STATE HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:SCURRY
Practice Address - State:TX
Practice Address - Zip Code:75158-3146
Practice Address - Country:US
Practice Address - Phone:469-212-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82408101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor