Individual
JOHN LUTHER BLAYLOCK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2432 W PEORIA AVE, PHOENIX, AZ 85029-4726
(480) 431-5075
Mailing address
2432 W PEORIA AVE, PHOENIX, AZ 85029-4726
(480) 431-5075
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NA
NA
—
Enumeration date
08/26/2021
Last updated
08/30/2021
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