Healthcare Provider Details

I. General information

NPI: 1639774144
Provider Name (Legal Business Name): BLAKELY MURRAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 03/12/2023
Certification Date: 03/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4931 RIVERSIDE DR STE 400A
MACON GA
31210-1195
US

IV. Provider business mailing address

3500 DEPAUW BLVD STE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 478-219-7626
  • Fax: 317-520-8200
Mailing address:
  • Phone: 855-324-0885
  • Fax: 317-520-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-64289
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-130471
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: