Provider Demographics
NPI:1184936775
Name:BLAKLEY, MICHAEL ALLEN (LMT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:BLAKLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2550 WINDY HILL RD SE
Mailing Address - Street 2:215
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8665
Mailing Address - Country:US
Mailing Address - Phone:770-850-8464
Mailing Address - Fax:
Practice Address - Street 1:2550 WINDY HILL RD SE
Practice Address - Street 2:215
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8665
Practice Address - Country:US
Practice Address - Phone:770-850-8464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000455225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist