Basic Information
| Provider Information | |||||||||
| NPI: | 1891769261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | BAKER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 590 FAR VIEW LN | ||||||||
| Address2: | |||||||||
| City: | ESTES PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805179049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705770606 | ||||||||
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| Practice Location | |||||||||
| Address1: | 928 12TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806314024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703364910 | ||||||||
| FaxNumber: | 9703365000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 992906 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.