Provider Demographics
NPI:1518214899
Name:BLAKELOCK, HAROLD HERBERT
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:HERBERT
Last Name:BLAKELOCK
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 1:1836 N 1120 W # 2
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1179
Mailing Address - Country:US
Mailing Address - Phone:801-722-8362
Mailing Address - Fax:
Practice Address - Street 1:1836 N 1120 W # 2
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1179
Practice Address - Country:US
Practice Address - Phone:801-722-8362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114279-2501103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic