Provider Demographics
NPI:1972507309
Name:BLAKEMAN, STEPHEN DALE (MA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DALE
Last Name:BLAKEMAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 CEDAR KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6248
Mailing Address - Country:US
Mailing Address - Phone:919-554-4343
Mailing Address - Fax:877-300-6893
Practice Address - Street 1:1012 CEDAR KNOLL DR
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6248
Practice Address - Country:US
Practice Address - Phone:919-554-4343
Practice Address - Fax:877-300-6893
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1556103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC142A0OtherBCBS
NC6107254Medicaid