Healthcare Provider Details

I. General information

NPI: 1235736505
Provider Name (Legal Business Name): STEPHEN PAUL BLAKLEY CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W BRANNAN ISLAND RD SPC 21
ISLETON CA
95641-9761
US

IV. Provider business mailing address

PO BOX 402
ISLETON CA
95641-0402
US

V. Phone/Fax

Practice location:
  • Phone: 916-600-1430
  • Fax:
Mailing address:
  • Phone: 916-600-1430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number17860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: