Healthcare Provider Details

I. General information

NPI: 1942629035
Provider Name (Legal Business Name): BLAKE ROBERT HARRIS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11010 DOMAIN DR APT 11331
AUSTIN TX
78758-7711
US

IV. Provider business mailing address

11010 DOMAIN DR APT 11331
AUSTIN TX
78758-7711
US

V. Phone/Fax

Practice location:
  • Phone: 214-837-7999
  • Fax:
Mailing address:
  • Phone: 214-837-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number36688
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: