Provider Demographics
NPI:1093875783
Name:BLAKE, MARY ELLEN (LPCC)
Entity type:Individual
Prefix:MRS
First Name:MARY ELLEN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 ELK DR
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-2218
Mailing Address - Country:US
Mailing Address - Phone:440-964-7196
Mailing Address - Fax:
Practice Address - Street 1:CATHOLIC CHARITIES
Practice Address - Street 2:4200 PARK AVE 3RD FLOOR
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004
Practice Address - Country:US
Practice Address - Phone:440-992-2121
Practice Address - Fax:440-992-5974
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE345101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health