Healthcare Provider Details

I. General information

NPI: 1285658385
Provider Name (Legal Business Name): BLAZE HARKEY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S MARION AVE VA MEDICAL CENTER
LAKE CITY FL
32025-5808
US

IV. Provider business mailing address

619 S MARION AVE VA MEDICAL CENTER
LAKE CITY FL
32025-5808
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-3016
  • Fax: 386-754-6387
Mailing address:
  • Phone: 386-755-3016
  • Fax: 386-754-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 3268
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 000884
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberHSP-P 0773
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: