Provider Demographics
NPI:1831532803
Name:BLAKELY, WHITNEY STANA (LCSW MSW)
Entity type:Individual
Prefix:MRS
First Name:WHITNEY
Middle Name:STANA
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:LCSW MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-3011
Mailing Address - Country:US
Mailing Address - Phone:815-979-8164
Mailing Address - Fax:815-399-5767
Practice Address - Street 1:415 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-3011
Practice Address - Country:US
Practice Address - Phone:815-979-8164
Practice Address - Fax:815-399-5767
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149015840104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker