Healthcare Provider Details

I. General information

NPI: 1205055761
Provider Name (Legal Business Name): ANGELA D BLAKELEY P.L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 69 BOX 1455
IRONTON MO
63650-9606
US

IV. Provider business mailing address

320 S PINE ST
BONNE TERRE MO
63628-1635
US

V. Phone/Fax

Practice location:
  • Phone: 573-546-7592
  • Fax: 573-546-0125
Mailing address:
  • Phone: 573-330-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2007008767
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: