Provider Demographics
NPI:1891955613
Name:BLACKLEY, LYNN GANTT (MA CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:GANTT
Last Name:BLACKLEY
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1302 EASTHAM DRIVE
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-8550
Mailing Address - Country:US
Mailing Address - Phone:919-387-0395
Mailing Address - Fax:919-387-9381
Practice Address - Street 1:1302 EASTHAM DR
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-8550
Practice Address - Country:US
Practice Address - Phone:919-387-0395
Practice Address - Fax:919-387-9381
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005214235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist