Provider Demographics
NPI:1639684681
Name:KLEPAL, BLAKE FORREST (LMHC)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:FORREST
Last Name:KLEPAL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:BLAKE
Other - Last Name:FORREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:PO BOX 748519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8519
Mailing Address - Country:US
Mailing Address - Phone:904-376-3800
Mailing Address - Fax:
Practice Address - Street 1:30 ARDISIA LN
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-3881
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-45567106S00000X
FLMH22337101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician