Provider Demographics
NPI:1417022468
Name:BLAKLEY, SHAWN THORNTON (MSE, CADCIII)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:THORNTON
Last Name:BLAKLEY
Suffix:
Gender:M
Credentials:MSE, CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E WALNUT ST
Mailing Address - Street 2:SUITE 706
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4239
Mailing Address - Country:US
Mailing Address - Phone:920-437-8256
Mailing Address - Fax:920-437-1188
Practice Address - Street 1:130 E WALNUT ST
Practice Address - Street 2:SUITE 706
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4239
Practice Address - Country:US
Practice Address - Phone:920-437-8256
Practice Address - Fax:920-437-1188
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WICADCIII101YA0400X
WI792-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39626900Medicaid