Healthcare Provider Details

I. General information

NPI: 1558201145
Provider Name (Legal Business Name): BLAKE PESETSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 S 51ST CT STE G
FORT SMITH AR
72903-3666
US

IV. Provider business mailing address

4300 ROGERS AVE STE 20
FORT SMITH AR
72903-3152
US

V. Phone/Fax

Practice location:
  • Phone: 405-714-7734
  • Fax:
Mailing address:
  • Phone: 405-714-7734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2603018
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: