Provider Demographics
NPI:1578676714
Name:BLAKE, DUDLEY DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:DUDLEY
Middle Name:DAVID
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:701 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6413
Mailing Address - Country:US
Mailing Address - Phone:208-336-0461
Mailing Address - Fax:208-422-1164
Practice Address - Street 1:BOISE VA MEDICAL CENTER
Practice Address - Street 2:500 WEST FORT STREET
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83701-4598
Practice Address - Country:US
Practice Address - Phone:208-422-1125
Practice Address - Fax:208-422-1164
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPSY313103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPSY313OtherSTATE PSYCHOLOGY LICENSE