Provider Demographics
NPI:1306350186
Name:HANSEN, BLAKE DARRELL (PHD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:DARRELL
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 W 50 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-3565
Mailing Address - Country:US
Mailing Address - Phone:801-419-5899
Mailing Address - Fax:
Practice Address - Street 1:1609 W 50 N
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3565
Practice Address - Country:US
Practice Address - Phone:801-419-5899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11235836-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1396085718Medicaid