Provider Demographics
NPI:1992311534
Name:BLAKES, EDDIE LEE JR (DBH, LIAC)
Entity type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:LEE
Last Name:BLAKES
Suffix:JR
Gender:
Credentials:DBH, LIAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 S DOBSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-6412
Mailing Address - Country:US
Mailing Address - Phone:480-521-5289
Mailing Address - Fax:480-386-9910
Practice Address - Street 1:2266 S DOBSON RD STE 200
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6412
Practice Address - Country:US
Practice Address - Phone:480-521-5289
Practice Address - Fax:480-386-9910
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLIAC-155298101Y00000X, 101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)