Healthcare Provider Details

I. General information

NPI: 1376447441
Provider Name (Legal Business Name): ISAIAH BLAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 S BALTIC PL
MERIDIAN ID
83642-5935
US

IV. Provider business mailing address

6692 S OROFINO CREEK PL
MERIDIAN ID
83642-9454
US

V. Phone/Fax

Practice location:
  • Phone: 208-740-0544
  • Fax:
Mailing address:
  • Phone: 541-405-5687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2771690
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: