Healthcare Provider Details

I. General information

NPI: 1124955711
Provider Name (Legal Business Name): BLAKE LEON MUSGRAVE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 S BARTON AVE
FRESNO CA
93702-2985
US

IV. Provider business mailing address

496 S BARTON AVE
FRESNO CA
93702-2985
US

V. Phone/Fax

Practice location:
  • Phone: 559-860-4422
  • Fax:
Mailing address:
  • Phone: 559-860-4422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: