Provider Demographics
NPI:1790484681
Name:RICHARDS, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:RICHARDS
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 1:127 QUICK RD
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:OH
Mailing Address - Zip Code:45344-9253
Mailing Address - Country:US
Mailing Address - Phone:937-845-3628
Mailing Address - Fax:
Practice Address - Street 1:1750 E 53RD ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-2828
Practice Address - Country:US
Practice Address - Phone:765-387-7663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician