Healthcare Provider Details

I. General information

NPI: 1093875783
Provider Name (Legal Business Name): MARY ELLEN BLAKE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CATHOLIC CHARITIES 4200 PARK AVE 3RD FLOOR
ASHTABULA OH
44004
US

IV. Provider business mailing address

1120 ELK DR
ASHTABULA OH
44004-2218
US

V. Phone/Fax

Practice location:
  • Phone: 440-992-2121
  • Fax: 440-992-5974
Mailing address:
  • Phone: 440-964-7196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE345
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: