Provider Demographics
NPI:1811020563
Name:BLAKLEY, KATHERINE JOAN
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:JOAN
Last Name:BLAKLEY
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 1:21370 RIDGEDALE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2708
Mailing Address - Country:US
Mailing Address - Phone:313-478-3901
Mailing Address - Fax:248-542-1533
Practice Address - Street 1:13929 HARPER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3672
Practice Address - Country:US
Practice Address - Phone:313-371-0055
Practice Address - Fax:313-371-1409
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator