Provider Demographics
NPI:1962046870
Name:BLAKEMAN, BROOKE MACKENZIE (MED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:MACKENZIE
Last Name:BLAKEMAN
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 N 16TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4446
Mailing Address - Country:US
Mailing Address - Phone:602-368-3282
Mailing Address - Fax:
Practice Address - Street 1:7600 N 16TH ST STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4446
Practice Address - Country:US
Practice Address - Phone:602-368-3282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000484103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst