MEDICARE: MRS. BRITTNEY JEAN BLAKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-22-205768	CO

General Provider Information

NPI Number	:	1942903661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRITTNEY JEAN BLAKE

Provider Business Mailing Address
First Line	:	445 E CHEYENNE MOUNTAIN BLVD STE C-372
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-1528
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6431 HONEY GRV APT 308
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-9521
Country	:	US
Telephone Number	:	325-203-2541
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2023
Last Update Date	:	03/22/2023

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