Provider Demographics
NPI:1831084110
Name:BLAKE, KELLY JAYNE (NBCC, LPC ASSOCIATE)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JAYNE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:NBCC, LPC ASSOCIATE
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JAYNE
Other - Last Name:KIRTLAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:807 RIVERWAY LN
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-7979
Mailing Address - Country:US
Mailing Address - Phone:512-736-1750
Mailing Address - Fax:
Practice Address - Street 1:807 RIVERWAY LN
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-7979
Practice Address - Country:US
Practice Address - Phone:512-736-1750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX98345101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional