MEDICARE: MR. BLAKE RANDOLPH NUNNELEY LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	67032	TX

General Provider Information

NPI Number	:	1326562901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BLAKE RANDOLPH NUNNELEY LPC

Provider Business Mailing Address
First Line	:	3626 N HALL ST STE 530
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-5105
Country	:	US
Telephone Number	:	214-606-2484
Fax Number	:	214-942-3304

Provider Business Practice Location Address
First Line	:	3626 N HALL ST STE 530
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-5105
Country	:	US
Telephone Number	:	214-606-2484
Fax Number	:	214-942-3304

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2017
Last Update Date	:	07/21/2022

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