Provider Demographics
NPI:1003522293
Name:GRANT, BLAKE ALAN (PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:ALAN
Last Name:GRANT
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 BANISTER LN STE 200C
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-8077
Mailing Address - Country:US
Mailing Address - Phone:806-893-1778
Mailing Address - Fax:
Practice Address - Street 1:4005 BANISTER LN STE 200C
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-8077
Practice Address - Country:US
Practice Address - Phone:512-328-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1109094363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health