Provider Demographics
NPI:1124568035
Name:BLAKELY, EVA MAE (MS/CCC-SLP)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:MAE
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2225
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-2225
Mailing Address - Country:US
Mailing Address - Phone:505-281-1811
Mailing Address - Fax:505-281-7704
Practice Address - Street 1:1090 MOUNTAIN VALLEY RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-8044
Practice Address - Country:US
Practice Address - Phone:505-281-1811
Practice Address - Fax:505-281-7704
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6153235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist