Provider Demographics
NPI:1225153273
Name:BLAKELEY, BONNIE (LCPC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:BLAKELEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 CORBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3545
Mailing Address - Country:US
Mailing Address - Phone:815-227-9771
Mailing Address - Fax:
Practice Address - Street 1:129 PHELPS AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2453
Practice Address - Country:US
Practice Address - Phone:815-227-9771
Practice Address - Fax:815-227-9793
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional