Healthcare Provider Details

I. General information

NPI: 1508404567
Provider Name (Legal Business Name): HALEY BLAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2019
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 HAMILTON RD STE 217
OKEMOS MI
48864-1700
US

IV. Provider business mailing address

5949 SELFRIDGE BLVD
LANSING MI
48911-4702
US

V. Phone/Fax

Practice location:
  • Phone: 517-295-3175
  • Fax:
Mailing address:
  • Phone: 517-910-3596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: