Provider Demographics
NPI:1669920377
Name:BLASKE, MARISOL CHRISTINE (BA)
Entity type:Individual
Prefix:
First Name:MARISOL
Middle Name:CHRISTINE
Last Name:BLASKE
Suffix:
Gender:F
Credentials:BA
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 12403
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10822 SE 82ND AVE
Practice Address - Street 2:STE K
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-7658
Practice Address - Country:US
Practice Address - Phone:503-654-7444
Practice Address - Fax:503-654-0392
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)