Provider Demographics
NPI:1578996567
Name:GILBERT, BLAKE MITCHELL
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:MITCHELL
Last Name:GILBERT
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 1:2624 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2350
Mailing Address - Country:US
Mailing Address - Phone:701-298-4500
Mailing Address - Fax:
Practice Address - Street 1:2611 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-4151
Practice Address - Country:US
Practice Address - Phone:815-625-0013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND599103T00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health