Provider Demographics
NPI:1598960064
Name:BLAKEY, TERALD
Entity Type:Individual
Prefix:
First Name:TERALD
Middle Name:
Last Name:BLAKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 E 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46407-2618
Mailing Address - Country:US
Mailing Address - Phone:219-886-1320
Mailing Address - Fax:219-886-1319
Practice Address - Street 1:308 E 21ST AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46407-2618
Practice Address - Country:US
Practice Address - Phone:219-886-1320
Practice Address - Fax:219-886-1319
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional