Healthcare Provider Details

I. General information

NPI: 1548180367
Provider Name (Legal Business Name): BLAISE SILKA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11225 N 28TH DR STE A210
PHOENIX AZ
85029-5646
US

IV. Provider business mailing address

12128 W EL CORTEZ PL
PEORIA AZ
85383-5840
US

V. Phone/Fax

Practice location:
  • Phone: 623-313-4739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-20726
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: