MEDICARE: MR. MARGARET LIPHAM BLAKELY MED, LPC

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	101YP2500X	Professional Counselor	10723	TX

General Provider Information

NPI Number	:	1518905132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARGARET LIPHAM BLAKELY MED, LPC

Provider Business Mailing Address
First Line	:	3212 COLLINSWORTH ST
Second Line	:	SUITE 101
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6580
Country	:	US
Telephone Number	:	817-877-3707
Fax Number	:	817-810-9585

Provider Business Practice Location Address
First Line	:	3212 COLLINSWORTH ST
Second Line	:	SUITE 101
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6580
Country	:	US
Telephone Number	:	817-877-3707
Fax Number	:	817-810-9585

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

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	07/08/2007

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