Provider Demographics
NPI:1205526043
Name:BLAKE, MASON
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:BLAKE
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:PO BOX 4456
Mailing Address - Street 2:
Mailing Address - City:WEST WENDOVER
Mailing Address - State:NV
Mailing Address - Zip Code:89883-4456
Mailing Address - Country:US
Mailing Address - Phone:720-934-9853
Mailing Address - Fax:
Practice Address - Street 1:850 ELM ST
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-3349
Practice Address - Country:US
Practice Address - Phone:775-738-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician