1396054193 NPI number — MRS. GLORIA CLEMENCIA BLAKLEY MA-CMHC-CABA

Table of content: MRS. GLORIA CLEMENCIA BLAKLEY MA-CMHC-CABA (NPI 1396054193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396054193 NPI number — MRS. GLORIA CLEMENCIA BLAKLEY MA-CMHC-CABA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKLEY
Provider First Name:
GLORIA
Provider Middle Name:
CLEMENCIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA-CMHC-CABA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396054193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8595 TANSY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32819-4512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-442-6683
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 N LAKEMONT AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32792-3205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-830-6412
Provider Business Practice Location Address Fax Number:
407-830-8413
Provider Enumeration Date:
09/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LCC05002 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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