Provider Demographics
NPI:1164875969
Name:EASTER SEALS BLAKE FOUNDATION
Entity Type:Organization
Organization Name:EASTER SEALS BLAKE FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EARLY CHILDHOOD THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ARENAS
Authorized Official - Suffix:
Authorized Official - Credentials:MAS-IFP, BHT
Authorized Official - Phone:480-416-9851
Mailing Address - Street 1:288 N IRONWOOD DR STE 115
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-3830
Mailing Address - Country:US
Mailing Address - Phone:480-416-9851
Mailing Address - Fax:
Practice Address - Street 1:288 N IRONWOOD DR STE 115
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-3830
Practice Address - Country:US
Practice Address - Phone:480-416-9851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center