Provider Demographics
NPI:1255657201
Name:ALTOM, BLAKE DENVER (MS, MFT INTERN)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:DENVER
Last Name:ALTOM
Suffix:
Gender:M
Credentials:MS, MFT INTERN
Other - Prefix:MR
Other - First Name:BLAKE
Other - Middle Name:
Other - Last Name:ALTOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BLAKE ALTOM
Mailing Address - Street 1:242 ROSEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-5045
Mailing Address - Country:US
Mailing Address - Phone:435-512-1304
Mailing Address - Fax:
Practice Address - Street 1:242 ROSEWOOD CIR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5045
Practice Address - Country:US
Practice Address - Phone:435-512-1304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7195889-3904106H00000X
253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist