Provider Demographics
NPI:1215222393
Name:BLAKE, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 MAY ROSE CIR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-7770
Mailing Address - Country:US
Mailing Address - Phone:775-378-1339
Mailing Address - Fax:
Practice Address - Street 1:2470 WRONDEL WAY
Practice Address - Street 2:SUITE 150B
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3701
Practice Address - Country:US
Practice Address - Phone:775-351-2211
Practice Address - Fax:775-351-2217
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst