Provider Demographics
NPI:1083219588
Name:BLAKELY, VONETTA BUTLER (LCSW)
Entity Type:Individual
Prefix:
First Name:VONETTA
Middle Name:BUTLER
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10337 ELVEN LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6964
Mailing Address - Country:US
Mailing Address - Phone:704-649-5627
Mailing Address - Fax:
Practice Address - Street 1:10337 ELVEN LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-6964
Practice Address - Country:US
Practice Address - Phone:704-649-5627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0135111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical