Individual
MISTEY LYNN BLAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MA TLLP CADC-M
Contact information
Practice address
50430 SCHOOL HOUSE RD, 100, CANTON, MI 48187-5910
(734) 495-1722
(734) 495-3068
Mailing address
50430 SCHOOL HOUSE RD, 100, CANTON, MI 48187-5910
(734) 495-1722
(734) 495-3068
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
6301015297
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
213119549
—
MI
Enumeration date
03/21/2013
Last updated
03/21/2013
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