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General NPI Number Information
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NPI Number | 1306594189
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Entity Type | Individual
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Provider Name | LAUREN ELIZABETH BLAKE LLMFT
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Gender | Female
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Dates
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Enumeration Date | 03/11/2022
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Last Update Date | 11/12/2022
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Provider Practice Location Address
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Address Line | 4769 NORVELL RD
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City | GRASS LAKE
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State | MI
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Zip | 49240-9726
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Country | US
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Telephone | 678-897-9796
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Fax |
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Provider Business Mailing Address
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Address Line | 4769 NORVELL RD
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City | GRASS LAKE
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State | MI
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Zip | 49240-9726
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Country | US
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Telephone | 678-897-9796
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 4151001039
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License Number State | MI
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