Healthcare Provider Details

I. General information

NPI: 1891605309
Provider Name (Legal Business Name): BLAKE THOMAS DISHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S MISSION ST
MOUNT PLEASANT MI
48858-2878
US

IV. Provider business mailing address

N1173 US HIGHWAY 8
NORWAY MI
49870-2049
US

V. Phone/Fax

Practice location:
  • Phone: 989-815-2157
  • Fax:
Mailing address:
  • Phone:
  • 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: