Provider Demographics
NPI:1508572819
Name:ANTHIS, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:ANTHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 TOUBY PIKE STE B
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-2573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:451 S PARK RIDGE RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8589
Practice Address - Country:US
Practice Address - Phone:317-334-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst