Healthcare Provider Details

I. General information

NPI: 1316530165
Provider Name (Legal Business Name): BLAKE SZYMCZAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N 25TH ST
GRAND JUNCTION CO
81501-6594
US

IV. Provider business mailing address

500 RAILYARD LOOP APT 519
GRAND JUNCTION CO
81505-7319
US

V. Phone/Fax

Practice location:
  • Phone: 970-235-4066
  • Fax:
Mailing address:
  • Phone: 307-277-5546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC.0025293
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: