Provider Demographics
NPI:1578805214
Name:EARL, BLAKE KELLY
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:KELLY
Last Name:EARL
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 1:3022 N 550 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2043
Mailing Address - Country:US
Mailing Address - Phone:801-791-2629
Mailing Address - Fax:
Practice Address - Street 1:5150 S. WASHINGTON BLVD.
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4503
Practice Address - Country:US
Practice Address - Phone:801-337-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor