Provider Demographics
NPI:1265297378
Name:SOULET, BLAKE GIOVANNI (LLC)
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:GIOVANNI
Last Name:SOULET
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5384 BENTLEY RD APT 106
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2189
Mailing Address - Country:US
Mailing Address - Phone:248-736-7541
Mailing Address - Fax:
Practice Address - Street 1:6960 ORCHARD LAKE RD STE 202
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4519
Practice Address - Country:US
Practice Address - Phone:248-985-9942
Practice Address - Fax:248-221-1775
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023525101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health