Healthcare Provider Details

I. General information

NPI: 1063344232
Provider Name (Legal Business Name): BROOKE BLAKENEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 BUTLER ST
MIDWAY GA
31320-4596
US

IV. Provider business mailing address

111 THORNBRIAR DR
HINESVILLE GA
31313-1016
US

V. Phone/Fax

Practice location:
  • Phone: 912-312-8924
  • Fax:
Mailing address:
  • Phone: 912-321-2167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: