Provider Demographics
NPI:1073042842
Name:BLAKE, TIFFANY NICHOLE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICHOLE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 W BEARCAT DR
Mailing Address - Street 2:
Mailing Address - City:S SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2519
Mailing Address - Country:US
Mailing Address - Phone:801-355-2846
Mailing Address - Fax:
Practice Address - Street 1:447 W BEARCAT DR
Practice Address - Street 2:
Practice Address - City:S SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-2519
Practice Address - Country:US
Practice Address - Phone:801-355-2846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health