Healthcare Provider Details

I. General information

NPI: 1326994286
Provider Name (Legal Business Name): BLAISE SELBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 W COLORADO AVE STE 101
COLORADO SPRINGS CO
80904-3350
US

IV. Provider business mailing address

2320 W COLORADO AVE STE 101
COLORADO SPRINGS CO
80904-3350
US

V. Phone/Fax

Practice location:
  • Phone: 719-888-9348
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC.0024540
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: