Provider Demographics
NPI:1932834785
Name:DOUGLAS, BLAKE M (LPC)
Entity Type:Individual
Prefix:MISS
First Name:BLAKE
Middle Name:M
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials: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 621
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-0621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 E MARGARET ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:IL
Practice Address - Zip Code:60476-1336
Practice Address - Country:US
Practice Address - Phone:708-855-1998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-17
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015522101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178.015522OtherIDFPR