Individual
MARIBETH BLAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.S.CCC-SLP
Contact information
Practice address
2801 S WEBSTER AVE, GREEN BAY, WI 54301-2878
(920) 337-1122
Mailing address
1527 GJERPEN LN, MANITOWOC, WI 54220-9765
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
1043-154
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1043-154
STATE LICENSE
WI
05
—
42717700
—
WI
Enumeration date
06/20/2007
Last updated
07/08/2007
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