MEDICARE: MR. STEPHEN DALE BLAKEMAN M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1556	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	142A0	OTHER	NC	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972507309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHEN DALE BLAKEMAN M.A.

Provider Business Mailing Address
First Line	:	1012 CEDAR KNOLL DR
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-6248
Country	:	US
Telephone Number	:	919-554-4343
Fax Number	:	877-300-6893

Provider Business Practice Location Address
First Line	:	1012 CEDAR KNOLL DR
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-6248
Country	:	US
Telephone Number	:	919-554-4343
Fax Number	:	877-300-6893

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	05/20/2008

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