Provider Demographics
NPI:1699226597
Name:BLAKELY, ELBERT Q (BCBA-D)
Entity Type:Individual
Prefix:
First Name:ELBERT
Middle Name:Q
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5058
Mailing Address - Country:US
Mailing Address - Phone:407-629-0165
Mailing Address - Fax:
Practice Address - Street 1:500 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4504
Practice Address - Country:US
Practice Address - Phone:407-218-4340
Practice Address - Fax:407-218-4303
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-01-0541103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019523800Medicaid