Provider Demographics
NPI:1114748951
Name:BLAKES, SHAKEYA TYNEICE
Entity type:Individual
Prefix:
First Name:SHAKEYA
Middle Name:TYNEICE
Last Name:BLAKES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHAKEYA
Other - Middle Name:TYNEICE
Other - Last Name:BLAKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASTERS
Mailing Address - Street 1:26 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-2161
Mailing Address - Country:US
Mailing Address - Phone:203-400-7304
Mailing Address - Fax:
Practice Address - Street 1:1 ENTERPRISE DR STE 415
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4631
Practice Address - Country:US
Practice Address - Phone:203-255-5078
Practice Address - Fax:203-295-7663
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00000000000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health