Provider Demographics
NPI:1902950959
Name:BLAKESLEE, MARY KELLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KELLY
Last Name:BLAKESLEE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 FRANKLIN PL
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3616
Mailing Address - Country:US
Mailing Address - Phone:908-598-0059
Mailing Address - Fax:908-598-0058
Practice Address - Street 1:25 FRANKLIN PL
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3616
Practice Address - Country:US
Practice Address - Phone:908-598-0059
Practice Address - Fax:908-598-0058
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00182200103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJBL700994Medicare ID - Type Unspecified