Provider Demographics
NPI:1336863539
Name:BLAKITA, COLLIN A
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:A
Last Name:BLAKITA
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 1:520 ALFORD RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:MI
Mailing Address - Zip Code:48131-9782
Mailing Address - Country:US
Mailing Address - Phone:734-896-1648
Mailing Address - Fax:
Practice Address - Street 1:41760 IVY ST STE 101
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9416
Practice Address - Country:US
Practice Address - Phone:951-595-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI04788600OtherUHC