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General NPI Number Information
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NPI Number | 1962084772
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Entity Type | Individual
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Provider Name | SHENLEY BLAKE
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Gender | Male
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Dates
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Enumeration Date | 04/22/2021
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Last Update Date | 04/22/2021
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Provider Practice Location Address
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Address Line | 5921 RIVA RIDGE DR
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City | WESLEY CHAPEL
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State | FL
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Zip | 33544-6517
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Country | US
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Telephone | 813-591-1403
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Fax |
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Provider Business Mailing Address
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Address Line | 6631 FORT KING RD APT 407
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City | ZEPHYRHILLS
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State | FL
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Zip | 33542-4843
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Country | US
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Telephone | 813-312-1927
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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 | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | RBT-21-161704
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License Number State | FL
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