1750602355 NPI number — KECIA MARIE BLAKELY MSPSY, LMHC

Table of content: KECIA MARIE BLAKELY MSPSY, LMHC (NPI 1750602355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750602355 NPI number — KECIA MARIE BLAKELY MSPSY, LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKELY
Provider First Name:
KECIA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPSY, LMHC
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:
1750602355
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1143 E IRELAND RD # 1003
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46614-3446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-208-3359
Provider Business Mailing Address Fax Number:
866-812-9889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
52189 SCOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46637-2952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-208-3359
Provider Business Practice Location Address Fax Number:
866-812-9889
Provider Enumeration Date:
06/17/2010

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: 101YM0800X , with the licence number:  39004492A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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