Healthcare Provider Details

I. General information

NPI: 1457069361
Provider Name (Legal Business Name): BLAKE JAMES GRONOWSKI M.ED, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MCDONALD CT
MYRTLE BEACH SC
29588-6134
US

IV. Provider business mailing address

3930 SAINT IVES RD UNIT 516
MYRTLE BEACH SC
29588-1164
US

V. Phone/Fax

Practice location:
  • Phone: 843-294-0646
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10340
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: