Provider Demographics
NPI:1710594445
Name:BLAKELY, INDIA (LCPC)
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18300 S. HALSTED
Mailing Address - Street 2:SUITE B MAILBOX 107
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425
Mailing Address - Country:US
Mailing Address - Phone:312-736-2060
Mailing Address - Fax:
Practice Address - Street 1:17337 WOODED PATH DR APT 3S
Practice Address - Street 2:
Practice Address - City:EAST HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2619
Practice Address - Country:US
Practice Address - Phone:708-805-9380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007413101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty