Provider Demographics
NPI:1518097559
Name:BLAKELY, TRICIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:765-741-0335
Practice Address - Street 1:931 W WATER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1755
Practice Address - Country:US
Practice Address - Phone:765-288-1928
Practice Address - Fax:765-741-0335
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004432A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000336982OtherBLUE CROSS BLUE SHIELD
IN740963000OtherMAGELLAN
IN000000336982OtherBLUE CROSS BLUE SHIELD