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General NPI Number Information
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NPI Number | 1053129114
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Entity Type | Individual
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Provider Name | BLAKE ODUS CONNELL RBT
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Gender | Male
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Dates
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Enumeration Date | 12/20/2024
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Last Update Date | 12/20/2024
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Provider Practice Location Address
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Address Line | 12175 NETWORK BLVD
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City | SAN ANTONIO
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State | TX
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Zip | 78249-3413
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Country | US
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Telephone | 210-797-7181
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Fax |
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Provider Business Mailing Address
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Address Line | 100 N SANTA ROSA APT 927
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City | SAN ANTONIO
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State | TX
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Zip | 78207-3269
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | 24-386636
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License Number State | CO
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