Provider Demographics
NPI:1669764155
Name:BLAKE, M LYNETTE (LPCC, NCC)
Entity type:Individual
Prefix:MS
First Name:M
Middle Name:LYNETTE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 SOUTHERN HILLS DRIVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102-9003
Mailing Address - Country:US
Mailing Address - Phone:606-922-4983
Mailing Address - Fax:606-393-5613
Practice Address - Street 1:4000 SOUTHERN HILLS DRIVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-9003
Practice Address - Country:US
Practice Address - Phone:606-922-4983
Practice Address - Fax:606-393-5613
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1091101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100326700Medicaid
WV0005355002Medicaid