Provider Demographics
NPI:1376296210
Name:BLAKESLEY, BIANCA (LICSW)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:BLAKESLEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 DOONE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2656
Mailing Address - Country:US
Mailing Address - Phone:857-249-2983
Mailing Address - Fax:
Practice Address - Street 1:20 DOONE AVE APT 2
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02126-2656
Practice Address - Country:US
Practice Address - Phone:857-249-2983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1225381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical