Healthcare Provider Details

I. General information

NPI: 1235061334
Provider Name (Legal Business Name): MELISSA BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WADE AVE
CATONSVILLE MD
21228-4663
US

IV. Provider business mailing address

2709 CHIPPEWA CT
FINKSBURG MD
21048-1536
US

V. Phone/Fax

Practice location:
  • Phone: 443-789-2199
  • Fax:
Mailing address:
  • Phone: 443-789-2199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17739
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: