Provider Demographics
NPI:1083920417
Name:BLEVINS, PATRICK R (BCBA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:R
Last Name:BLEVINS
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 CALLE LOS VECINOS NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-2803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1851
Practice Address - Country:US
Practice Address - Phone:505-272-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2021-08-11
Deactivation Date:2015-04-20
Deactivation Code:
Reactivation Date:2016-03-29
Provider Licenses
StateLicense IDTaxonomies
NM1-15-19141103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst