Provider Demographics
NPI:1649938291
Name:SMITH, DONAVEN BLAKE
Entity type:Individual
Prefix:
First Name:DONAVEN
Middle Name:BLAKE
Last Name:SMITH
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 1:350 ARAPAHOE AVE APT 23
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5842
Mailing Address - Country:US
Mailing Address - Phone:720-590-2641
Mailing Address - Fax:
Practice Address - Street 1:2935 BASELINE RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2366
Practice Address - Country:US
Practice Address - Phone:303-545-0844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator