Healthcare Provider Details

I. General information

NPI: 1437870813
Provider Name (Legal Business Name): BLAKE THOMAS HUTCHESON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W LAKEVIEW AVE
PENSACOLA FL
32501-1836
US

IV. Provider business mailing address

1221 W LAKEVIEW AVE
PENSACOLA FL
32501-1836
US

V. Phone/Fax

Practice location:
  • Phone: 417-569-8907
  • Fax: 850-595-1400
Mailing address:
  • Phone: 417-569-8907
  • Fax: 850-595-1400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT22-233033
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: