Provider Demographics
NPI:1043668908
Name:BLAKELY, MATTHEW (LICSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RANDALL RD UNIT 439
Mailing Address - Street 2:
Mailing Address - City:WRENTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02093-7023
Mailing Address - Country:US
Mailing Address - Phone:508-281-9373
Mailing Address - Fax:
Practice Address - Street 1:38 MECHANIC ST STE 201
Practice Address - Street 2:
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035-2072
Practice Address - Country:US
Practice Address - Phone:508-281-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1223511041C0700X
MA222988104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical