Provider Demographics
NPI:1871652818
Name:BLAKELY, GAIL JOAN (LADC 1)
Entity Type:Individual
Prefix:MS
First Name:GAIL
Middle Name:JOAN
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO B 3163
Mailing Address - Street 2:
Mailing Address - City:WAQUIOT
Mailing Address - State:MA
Mailing Address - Zip Code:02536
Mailing Address - Country:US
Mailing Address - Phone:508-548-1349
Mailing Address - Fax:508-548-1349
Practice Address - Street 1:50 ALDRIN RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360
Practice Address - Country:US
Practice Address - Phone:508-830-0004
Practice Address - Fax:508-830-0295
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1008101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1008OtherLICENSE NUMBER