MEDICARE: DR. MARIA CLARK BLAKE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3423	OH
2	103TC0700X	Clinical Psychologist	399	KY

General Provider Information

NPI Number	:	1316932049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIA CLARK BLAKE PHD

Provider Business Mailing Address
First Line	:	3358 MORRISON AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45220-1434
Country	:	US
Telephone Number	:	513-961-1555
Fax Number	:

Provider Business Practice Location Address
First Line	:	3358 MORRISON AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45220-1434
Country	:	US
Telephone Number	:	513-961-1555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	07/08/2007

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