Provider Demographics
NPI:1609681899
Name:BLAKE, MADISON TAYLOR
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8601 N KENTUCKY AVE STE C
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47725-6371
Mailing Address - Country:US
Mailing Address - Phone:812-636-1533
Mailing Address - Fax:317-536-3585
Practice Address - Street 1:8601 N KENTUCKY AVE STE C
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47725-6371
Practice Address - Country:US
Practice Address - Phone:812-636-1533
Practice Address - Fax:317-536-3585
Is Sole Proprietor?:No
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician