Provider Demographics
NPI:1669826723
Name:BRISBOIS, BLAKE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:BRISBOIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 TOWNSGATE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VLG
Mailing Address - State:CA
Mailing Address - Zip Code:91361-5754
Mailing Address - Country:US
Mailing Address - Phone:805-497-0605
Mailing Address - Fax:805-371-4862
Practice Address - Street 1:2625 TOWNSGATE RD STE 210
Practice Address - Street 2:
Practice Address - City:WESTLAKE VLG
Practice Address - State:CA
Practice Address - Zip Code:91361-5754
Practice Address - Country:US
Practice Address - Phone:805-497-0605
Practice Address - Fax:805-371-4862
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32519103TC0700X
CAPSY32519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical