Healthcare Provider Details

I. General information

NPI: 1699226597
Provider Name (Legal Business Name): ELBERT Q BLAKELY BCBA-D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E COLONIAL DR
ORLANDO FL
32803-4504
US

IV. Provider business mailing address

1295 RICHMOND RD
WINTER PARK FL
32789-5058
US

V. Phone/Fax

Practice location:
  • Phone: 407-218-4340
  • Fax: 407-218-4303
Mailing address:
  • Phone: 407-629-0165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-01-0541
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: