Provider Demographics
NPI:1699586271
Name:BLAKE, KIANA L (RBT)
Entity type:Individual
Prefix:
First Name:KIANA
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 SW ALADDIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1748
Mailing Address - Country:US
Mailing Address - Phone:954-864-0324
Mailing Address - Fax:
Practice Address - Street 1:2038 SW ALADDIN ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1748
Practice Address - Country:US
Practice Address - Phone:954-864-0324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician