Healthcare Provider Details

I. General information

NPI: 1043644891
Provider Name (Legal Business Name): MS. JANELLE HERMA BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JANELLE HERMA YOUNG C.A.C. III

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7290 SAMUEL DR SUITE 110
DENVER CO
80221-2743
US

IV. Provider business mailing address

7290 SAMUEL DR SUITE 110
DENVER CO
80221-2743
US

V. Phone/Fax

Practice location:
  • Phone: 303-487-7776
  • Fax: 303-487-7868
Mailing address:
  • Phone: 303-487-7776
  • Fax: 303-487-7868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number635
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: