Healthcare Provider Details

I. General information

NPI: 1649850587
Provider Name (Legal Business Name): BLAKE ZODA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 NE KELLY AVE # 100C
GRESHAM OR
97030-5629
US

IV. Provider business mailing address

21600 OXNARD ST STE 1800
WOODLAND HILLS CA
91367-7807
US

V. Phone/Fax

Practice location:
  • Phone: 503-912-5502
  • Fax:
Mailing address:
  • Phone: 818-345-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberABA-IN-10213415
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: