Provider Demographics
NPI:1629385323
Name:BLAKE, MALLAREE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MALLAREE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 W 26TH AVE STE 465C
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-5315
Mailing Address - Country:US
Mailing Address - Phone:720-386-4046
Mailing Address - Fax:
Practice Address - Street 1:2460 W 26TH AVE STE 465C
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-5315
Practice Address - Country:US
Practice Address - Phone:720-386-4046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2020-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004702103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical