Provider Demographics
NPI:1881015832
Name:BLAKELY, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21902-0000
Mailing Address - Country:US
Mailing Address - Phone:410-642-2411
Mailing Address - Fax:
Practice Address - Street 1:515 BROAD ST
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MD
Practice Address - Zip Code:21903-2678
Practice Address - Country:US
Practice Address - Phone:410-642-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker