MEDICARE: KELLY BLAKEY MSW

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	104100000X	Social Worker
2	104100000X	Social Worker	BH-3651	AZ

General Provider Information

NPI Number	:	1437201233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BLAKEY MSW

Provider Business Mailing Address
First Line	:	P.O. BOX 16906
Second Line	:	HUMAN SERVICES CONSULTANTS
City	:	PHOENIX
State	:	AZ
Zip	:	85011-6906
Country	:	US
Telephone Number	:	602-524-9406
Fax Number	:	602-279-1431

Provider Business Practice Location Address
First Line	:	42631 NORTH 43RD DRIVE
Second Line	:	KELLY'S ADULT THERAPEUTIC FOSTER HOME
City	:	NEW RIVER
State	:	AZ
Zip	:	85087
Country	:	US
Telephone Number	:	623-670-4139
Fax Number	:	623-551-8185

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

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	10/27/2010

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