Provider Demographics
NPI:1063047686
Name:BLAKELY, KATHERINE ANNE (LMSW)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:BLAKELY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:100 PINEWILD DRIVE
Mailing Address - Street 2:SECOND FLOOR SUITE A
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 PINEWILD DRIVE
Practice Address - Street 2:SECOND FLOOR SUITE A
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606
Practice Address - Country:US
Practice Address - Phone:585-368-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106230-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker