Provider Demographics
NPI:1083476097
Name:BLAYLOCK, MICHAEL ARLEN (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ARLEN
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 2ND AVE N STE 201
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6163
Mailing Address - Country:US
Mailing Address - Phone:208-751-0478
Mailing Address - Fax:
Practice Address - Street 1:155 2ND AVE N STE 201
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6163
Practice Address - Country:US
Practice Address - Phone:208-751-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10204101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health