Healthcare Provider Details

I. General information

NPI: 1114748951
Provider Name (Legal Business Name): SHAKEYA TYNEICE BLAKES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHAKEYA TYNEICE BLAKES MASTERS

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ENTERPRISE DR STE 415
SHELTON CT
06484-4631
US

IV. Provider business mailing address

26 CRESCENT ST
ANSONIA CT
06401-2161
US

V. Phone/Fax

Practice location:
  • Phone: 203-255-5078
  • Fax: 203-295-7663
Mailing address:
  • Phone: 203-400-7304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00000000000
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: