Healthcare Provider Details

I. General information

NPI: 1598446395
Provider Name (Legal Business Name): KECIA BLAKELY, MSP, LMHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52189 SCOTT ST
SOUTH BEND IN
46637
US

IV. Provider business mailing address

52189 SCOTT ST
SOUTH BEND IN
46637-2952
US

V. Phone/Fax

Practice location:
  • Phone: 574-208-3359
  • Fax:
Mailing address:
  • Phone: 574-800-9681
  • 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: KECIA MARIE BLAKELY
Title or Position: OWNER
Credential: LMHC
Phone: 574-800-9681