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NPI Code Detail

MEDICARE: MRS. TRICIA BLAKELY LCSW

MEDICARE: MRS. TRICIA BLAKELY LCSW
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
11041C0700XClinical Social Worker34004432AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1000000336982OTHERINBLUE CROSS BLUE SHIELD
2740963000OTHERINMAGELLAN

General Provider Information

NPI Number : 1518097559
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. TRICIA BLAKELY LCSW
Provider Business Mailing Address
First Line : 240 N TILLOTSON AVE
Second Line :
City : MUNCIE
State : IN
Zip : 47304-3988
Country : US
Telephone Number : 765-288-1928
Fax Number : 765-741-0335
Provider Business Practice Location Address
First Line : 931 W WATER ST
Second Line :
City : PORTLAND
State : IN
Zip : 47371-1755
Country : US
Telephone Number : 765-288-1928
Fax Number : 765-741-0335
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/07/2007
Last Update Date : 11/25/2014

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