Provider Demographics
NPI:1154147320
Name:DICKEY, BLAKE ALAN (MSC)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ALAN
Last Name:DICKEY
Suffix:
Gender:M
Credentials:MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 BARBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-8822
Mailing Address - Country:US
Mailing Address - Phone:952-688-7330
Mailing Address - Fax:
Practice Address - Street 1:10650 RED CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9117
Practice Address - Country:US
Practice Address - Phone:651-493-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst