Provider Demographics
NPI:1205055761
Name:BLAKELEY, ANGELA D (PLPC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:BLAKELEY
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1635
Mailing Address - Country:US
Mailing Address - Phone:573-330-6513
Mailing Address - Fax:
Practice Address - Street 1:HC 69 BOX 1455
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:MO
Practice Address - Zip Code:63650-9606
Practice Address - Country:US
Practice Address - Phone:573-546-7592
Practice Address - Fax:573-546-0125
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007008767101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional