MEDICARE: MRS. CRYSTAL S BLAKE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	C.0501154	OH

General Provider Information

NPI Number	:	1679896724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL S BLAKE PC

Provider Business Mailing Address
First Line	:	3413 ROSEDALE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44112-3010
Country	:	US
Telephone Number	:	216-533-8846
Fax Number	:

Provider Business Practice Location Address
First Line	:	3413 ROSEDALE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44112-3010
Country	:	US
Telephone Number	:	216-533-8846
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2010
Last Update Date	:	03/03/2010

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