Healthcare Provider Details

I. General information

NPI: 1427336494
Provider Name (Legal Business Name): MR. TERRY BLAKENEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HARRIS SPRINGS ROAD
LAS VEGAS NV
89124-7817
US

IV. Provider business mailing address

3936 SAVOY CT
LAS VEGAS NV
89115-0316
US

V. Phone/Fax

Practice location:
  • Phone: 702-872-5382
  • Fax:
Mailing address:
  • Phone: 702-757-5801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADC-I 01197
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCADC-I 01197
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: