Provider Demographics
NPI:1922680545
Name:BLALOCK, BREE ANA (SUDP, MHP)
Entity Type:Individual
Prefix:
First Name:BREE
Middle Name:ANA
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:SUDP, MHP
Other - Prefix:
Other - First Name:BREE
Other - Middle Name:ANA
Other - Last Name:BLALOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6050 41ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98136-1606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 E 4TH PLAIN BLVD BLDG 17
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3717
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61055353101YM0800X
WACP60417920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health