Healthcare Provider Details

I. General information

NPI: 1194594325
Provider Name (Legal Business Name): BLAKE K PATTERSON AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2023
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15078 S 2815 W
BLUFFDALE UT
84065-1724
US

IV. Provider business mailing address

15078 S 2815 W
BLUFFDALE UT
84065-1724
US

V. Phone/Fax

Practice location:
  • Phone: 214-769-5139
  • Fax:
Mailing address:
  • Phone: 801-867-3472
  • Fax: 801-401-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number12987596-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: