Provider Demographics
NPI:1780765909
Name:BLAKELY, STEVEN BRYAN
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:BRYAN
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEVEN
Other - Middle Name:BRYAN
Other - Last Name:BLAKELY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1587 OBERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-2042
Mailing Address - Country:US
Mailing Address - Phone:805-381-1107
Mailing Address - Fax:
Practice Address - Street 1:1587 OBERLIN AVE
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-2042
Practice Address - Country:US
Practice Address - Phone:805-381-1107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 20483103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical