Healthcare Provider Details

I. General information

NPI: 1356512180
Provider Name (Legal Business Name): CHANDRA BLAKELY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 LAKEWOOD WAY SUITE 205
ATLANTA GA
30315
US

IV. Provider business mailing address

215 LAKEWOOD WAY SUITE 205
ATLANTA GA
30315
US

V. Phone/Fax

Practice location:
  • Phone: 678-335-9010
  • Fax:
Mailing address:
  • Phone: 678-335-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005008
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: