Provider Demographics
NPI:1578889754
Name:BLAKELY, VERONICA
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:BLAKELY
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 1:3855 PRESIDENTIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-3705
Mailing Address - Country:US
Mailing Address - Phone:770-451-6838
Mailing Address - Fax:770-451-7804
Practice Address - Street 1:3855 PRESIDENTIAL PKWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-3705
Practice Address - Country:US
Practice Address - Phone:770-451-6838
Practice Address - Fax:770-451-7804
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005630101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health