Provider Demographics
NPI:1144762691
Name:BLAKENEY, SHONTAY (MA)
Entity Type:Individual
Prefix:
First Name:SHONTAY
Middle Name:
Last Name:BLAKENEY
Suffix:
Gender:F
Credentials:MA
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 1703
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32802-1703
Mailing Address - Country:US
Mailing Address - Phone:843-510-4702
Mailing Address - Fax:
Practice Address - Street 1:7550 FUTURES DR
Practice Address - Street 2:105,104
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9095
Practice Address - Country:US
Practice Address - Phone:407-730-7983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 15043101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health