MEDICARE: DR. COLETTE BLAKELY LCPC

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	178003235	IL
2	101YM0800X	Mental Health Counselor	180009264	IL

General Provider Information

NPI Number	:	1871672337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COLETTE BLAKELY LCPC

Provider Business Mailing Address
First Line	:	4521 N MOZART ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3816
Country	:	US
Telephone Number	:	312-203-2158
Fax Number	:

Provider Business Practice Location Address
First Line	:	4521 N MOZART ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3816
Country	:	US
Telephone Number	:	312-203-2158
Fax Number	:	312-203-2158

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	09/08/2016

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