Healthcare Provider Details

I. General information

NPI: 1871867945
Provider Name (Legal Business Name): BLAKE KEITHLEY M.S ED.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2012
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 Q ST
BEDFORD IN
47421-4718
US

IV. Provider business mailing address

840 W FRANK ST
MITCHELL IN
47446-1748
US

V. Phone/Fax

Practice location:
  • Phone: 812-279-4673
  • Fax: 812-279-4672
Mailing address:
  • Phone: 812-583-5094
  • 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: