Provider Demographics
NPI:1669122172
Name:BLAKE, EDITH Z (MS, LSSP, LPC)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:Z
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MS, LSSP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1135
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023
Mailing Address - Country:US
Mailing Address - Phone:210-757-3303
Mailing Address - Fax:
Practice Address - Street 1:4939 DE ZAVALA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2046
Practice Address - Country:US
Practice Address - Phone:210-757-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-27
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81672101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health