Individual
DR. DUDLEY DAVID BLAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
BOISE VA MEDICAL CENTER, 500 WEST FORT STREET, BOISE, ID 83701-4598
(208) 422-1125
(208) 422-1164
Mailing address
701 E JEFFERSON ST, BOISE, ID 83712-6413
(208) 336-0461
(208) 422-1164
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
PSY313
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PSY313
STATE PSYCHOLOGY LICENSE
ID
Enumeration date
08/15/2006
Last updated
07/08/2007
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