=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033831854
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAKE SLATER MA, BCBA, LBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2022
-----------------------------------------------------
Last Update Date | 09/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 CEDAR RD
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-987-9273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 CEDAR RD
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 002216-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------