Provider Demographics
NPI:1316932049
Name:BLAKE, MARIA CLARK (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:CLARK
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3358 MORRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-1434
Mailing Address - Country:US
Mailing Address - Phone:513-961-1555
Mailing Address - Fax:
Practice Address - Street 1:3358 MORRISON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-1434
Practice Address - Country:US
Practice Address - Phone:513-961-1555
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3423103TC0700X
KY399103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBLCP17481Medicare ID - Type Unspecified