Provider Demographics
NPI:1609359090
Name:SHUPE, BLAKE ANDREW (AOD COUNSELOR)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ANDREW
Last Name:SHUPE
Suffix:
Gender:M
Credentials:AOD COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 ROAD E
Mailing Address - Street 2:
Mailing Address - City:REDWOOD VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95470-9517
Mailing Address - Country:US
Mailing Address - Phone:707-462-6290
Mailing Address - Fax:
Practice Address - Street 1:201 BRUSH ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-3424
Practice Address - Country:US
Practice Address - Phone:707-462-6290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7581101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7581OtherCADTP