Provider Demographics
NPI:1093437451
Name:INOUYE, BLAKE R (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:R
Last Name:INOUYE
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3874 S EASTWOOD LN # B
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3450
Mailing Address - Country:US
Mailing Address - Phone:702-824-5038
Mailing Address - Fax:
Practice Address - Street 1:12637 S 265 W
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5400
Practice Address - Country:US
Practice Address - Phone:801-609-4086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst