Provider Demographics
NPI:1548537772
Name:BERRY, BLAKE NELSON
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:NELSON
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 W WARM SPRINGS RD
Mailing Address - Street 2:129
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-7633
Mailing Address - Country:US
Mailing Address - Phone:702-806-8618
Mailing Address - Fax:702-944-7846
Practice Address - Street 1:1481 W WARM SPRINGS RD
Practice Address - Street 2:129
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-7633
Practice Address - Country:US
Practice Address - Phone:702-806-8618
Practice Address - Fax:702-944-7846
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor