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General NPI Number Information
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NPI Number | 1184936775
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Entity Type | Individual
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Provider Name | MICHAEL ALLEN BLAKLEY LMT
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Gender | Male
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Dates
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Enumeration Date | 07/12/2010
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Last Update Date | 07/12/2010
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Provider Practice Location Address
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Address Line | 2550 WINDY HILL RD SE 215
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City | MARIETTA
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State | GA
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Zip | 30067-8665
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Country | US
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Telephone | 770-850-8464
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Fax |
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Provider Business Mailing Address
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Address Line | 2550 WINDY HILL RD SE 215
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City | MARIETTA
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State | GA
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Zip | 30067-8665
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Country | US
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Telephone | 770-850-8464
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT000455
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License Number State | GA
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