Provider Demographics
NPI:1548732910
Name:VETTER, BLAKE (RBT)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:VETTER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W DIVIDE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1224
Mailing Address - Country:US
Mailing Address - Phone:701-204-7870
Mailing Address - Fax:
Practice Address - Street 1:1221 W DIVIDE AVE STE 2
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1224
Practice Address - Country:US
Practice Address - Phone:701-204-7870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRBT-18-74104106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician