Provider Demographics
NPI:1316174717
Name:BLAKE, CHRISTAL G
Entity type:Individual
Prefix:
First Name:CHRISTAL
Middle Name:G
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W KING ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-6047
Mailing Address - Country:US
Mailing Address - Phone:509-307-8302
Mailing Address - Fax:
Practice Address - Street 1:206 W KING ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6047
Practice Address - Country:US
Practice Address - Phone:509-307-8302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60144840101Y00000X
WARC60101070101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor