Provider Demographics
NPI:1225836497
Name:CARROLL, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:CARROLL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5114 W 87TH ST S
Practice Address - Street 2:
Practice Address - City:HAYSVILLE
Practice Address - State:KS
Practice Address - Zip Code:67060-7335
Practice Address - Country:US
Practice Address - Phone:970-310-6540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician