Healthcare Provider Details

I. General information

NPI: 1336694934
Provider Name (Legal Business Name): VIRGINIA BLAKELY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 TURNER ST
LANSING MI
48906-4373
US

IV. Provider business mailing address

1310 TURNER ST
LANSING MI
48906-4373
US

V. Phone/Fax

Practice location:
  • Phone: 517-574-4197
  • Fax:
Mailing address:
  • Phone: 517-574-4197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: