Healthcare Provider Details

I. General information

NPI: 1528135795
Provider Name (Legal Business Name): BETH ANN BLAKESLEE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 N US HIGHWAY 51
JANESVILLE WI
53545-0726
US

IV. Provider business mailing address

911 LEXINGTON WAY
WAUNAKEE WI
53597-2105
US

V. Phone/Fax

Practice location:
  • Phone: 608-757-5215
  • Fax: 608-757-5231
Mailing address:
  • Phone: 608-850-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number37953 020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: