Provider Demographics
NPI:1750602355
Name:BLAKELY, KECIA MARIE (MSPSY, LMHC)
Entity type:Individual
Prefix:
First Name:KECIA
Middle Name:MARIE
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:MSPSY, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 E IRELAND RD # 1003
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-3446
Mailing Address - Country:US
Mailing Address - Phone:574-208-3359
Mailing Address - Fax:866-812-9889
Practice Address - Street 1:52189 SCOTT ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-2952
Practice Address - Country:US
Practice Address - Phone:574-208-3359
Practice Address - Fax:866-812-9889
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39004492A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health