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General NPI Number Information
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NPI Number | 1710594445
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Entity Type | Individual
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Provider Name | INDIA BLAKELY LCPC
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Gender | Female
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Dates
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Enumeration Date | 09/27/2020
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Last Update Date | 09/27/2020
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Provider Practice Location Address
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Address Line | 17337 WOODED PATH DR APT 3S
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City | EAST HAZEL CREST
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State | IL
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Zip | 60429-2619
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Country | US
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Telephone | 708-805-9380
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Fax |
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Provider Business Mailing Address
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Address Line | 18300 S. HALSTED SUITE B MAILBOX 107
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City | GLENWOOD
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State | IL
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Zip | 60425
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Country | US
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Telephone | 312-736-2060
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 180007413
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License Number State | IL
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