Provider Demographics
NPI:1104907476
Name:BLAKELY, TINA (LPC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6059 S QUEBEC ST STE 203
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80111-4523
Mailing Address - Country:US
Mailing Address - Phone:303-741-3005
Mailing Address - Fax:303-220-5064
Practice Address - Street 1:6059 S QUEBEC ST STE 203
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80111-4523
Practice Address - Country:US
Practice Address - Phone:303-741-3005
Practice Address - Fax:303-220-5064
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1246101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional