Healthcare Provider Details

I. General information

NPI: 1124931860
Provider Name (Legal Business Name): MICHELE BLAKE CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 MEMORIAL DR
FENNVILLE MI
49408-9370
US

IV. Provider business mailing address

251 W 22ND ST
HOLLAND MI
49423-4706
US

V. Phone/Fax

Practice location:
  • Phone: 269-722-3919
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101009158
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: