Provider Demographics
NPI:1457387466
Name:BLAKE, ROBERT R (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
Last Name:BLAKE
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 1:7974 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2971
Mailing Address - Country:US
Mailing Address - Phone:317-338-4692
Mailing Address - Fax:317-338-4693
Practice Address - Street 1:8433 HARCOURT RD
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2190
Practice Address - Country:US
Practice Address - Phone:317-338-4692
Practice Address - Fax:317-338-4693
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040385103TC0700X, 103TH0100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000184454OtherANTHEM/ BC PROVIDER #
IN100131760AMedicaid