MEDICARE: MR. TOMMY L BLAKEMAN M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	6787	TX
2	101YM0800X	Mental Health Counselor	63187	TX

General Provider Information

NPI Number	:	1104063742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TOMMY L BLAKEMAN M.S.

Provider Business Mailing Address
First Line	:	710 CHANDLER CT
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75002-3617
Country	:	US
Telephone Number	:	972-548-5570
Fax Number	:	972-548-5579

Provider Business Practice Location Address
First Line	:	2600 AVENUE K
Second Line	:	SUITE
City	:	PLANO
State	:	TX
Zip	:	75074-5306
Country	:	US
Telephone Number	:	972-548-5570
Fax Number	:	972-548-5579

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2009
Last Update Date	:	12/28/2009

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