Provider Demographics
NPI:1659651412
Name:BLAKESLEY, NICOLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:BLAKESLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:CHASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3264 VAIL PASS DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917
Mailing Address - Country:US
Mailing Address - Phone:626-375-3172
Mailing Address - Fax:
Practice Address - Street 1:3264 VAIL PASS DRIVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917
Practice Address - Country:US
Practice Address - Phone:626-375-3172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSYC.00013352103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical