Healthcare Provider Details

I. General information

NPI: 1851097455
Provider Name (Legal Business Name): ANEQUA BLAKELY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 216TH ST SW STE 100
MOUNTLAKE TERRACE WA
98043-2089
US

IV. Provider business mailing address

100 N HOWARD ST STE W
SPOKANE WA
99201-0508
US

V. Phone/Fax

Practice location:
  • Phone: 425-640-7009
  • Fax:
Mailing address:
  • Phone: 512-213-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC61476232
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: