Healthcare Provider Details

I. General information

NPI: 1881314078
Provider Name (Legal Business Name): BLAKE WILLIAM BARE CAPSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 GAMMON LN
MADISON WI
53719-2210
US

IV. Provider business mailing address

428 W WILSON ST
MADISON WI
53703-3614
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-8144
  • Fax:
Mailing address:
  • Phone: 920-253-9204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number132878-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: