Provider Demographics
NPI:1225217706
Name:BLAQUE, MELISSA L
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:L
Last Name:BLAQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 I.C. KING RD.
Mailing Address - Street 2:BROOKHAVEN RETREAT
Mailing Address - City:SEYMOUR
Mailing Address - State:TN
Mailing Address - Zip Code:37865
Mailing Address - Country:US
Mailing Address - Phone:865-573-3656
Mailing Address - Fax:865-609-6216
Practice Address - Street 1:1016 I.C. KING RD.
Practice Address - Street 2:BROOKHAVEN RETREAT
Practice Address - City:SEYMOUR
Practice Address - State:TN
Practice Address - Zip Code:37865
Practice Address - Country:US
Practice Address - Phone:865-573-3656
Practice Address - Fax:865-609-6216
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator