Provider Demographics
NPI:1942629035
Name:HARRIS, BLAKE ROBERT (PHD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ROBERT
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11010 DOMAIN DR
Mailing Address - Street 2:APT 11331
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-7711
Mailing Address - Country:US
Mailing Address - Phone:214-837-7999
Mailing Address - Fax:
Practice Address - Street 1:11010 DOMAIN DR
Practice Address - Street 2:APT 11331
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-7711
Practice Address - Country:US
Practice Address - Phone:214-837-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36688103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic