Provider Demographics
NPI:1003322132
Name:BLAKESLEE, JOY (MA, WSC)
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:
Last Name:BLAKESLEE
Suffix:
Gender:F
Credentials:MA, WSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 COLUMBRINA CIR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3334
Mailing Address - Country:US
Mailing Address - Phone:772-212-5695
Mailing Address - Fax:772-361-6350
Practice Address - Street 1:3100 COLUMBRINA CIR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3334
Practice Address - Country:US
Practice Address - Phone:772-212-5695
Practice Address - Fax:772-361-6350
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021924900Medicaid