Provider Demographics
NPI:1275108599
Name:BLAKENEY, AHMAD (LCAS-A)
Entity type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:BLAKENEY
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:AHMAD
Other - Middle Name:
Other - Last Name:BLAKENEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCAS-A
Mailing Address - Street 1:4401 E INDEPENDENCE BLVD STE 208-G
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4401 E INDEPENDENCE BLVD STE 208-G
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7485
Practice Address - Country:US
Practice Address - Phone:704-208-8038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS27033101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLCAS27033OtherSTATE LICENSE