Provider Demographics
NPI:1386913416
Name:BLAKE, CHRISTOPHER V (LPC)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:V
Last Name:BLAKE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:64 ROBBINS ST
Mailing Address - Street 2:WATERBURY HOSPITAL CRISIS CENTER
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2613
Mailing Address - Country:US
Mailing Address - Phone:203-573-6103
Mailing Address - Fax:203-573-7240
Practice Address - Street 1:64 ROBBINS ST
Practice Address - Street 2:WATERBURY HOSPITAL CRISIS CENTER
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2613
Practice Address - Country:US
Practice Address - Phone:203-573-6103
Practice Address - Fax:203-573-7240
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002120101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional