Provider Demographics
NPI:1245862200
Name:BLAKE, GABRIELLE (CDCA)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7939 CASTLE ROCK DR NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-1412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:NEWTON FALLS
Practice Address - State:OH
Practice Address - Zip Code:44444-1745
Practice Address - Country:US
Practice Address - Phone:330-953-0243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.171613101YA0400X
OHC.2103079101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)