Provider Demographics
NPI:1285716480
Name:BLACHLY-FLANAGAN, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BLACHLY-FLANAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 933421
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:937-641-6129
Practice Address - Street 1:700 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-1303
Practice Address - Country:US
Practice Address - Phone:937-641-4040
Practice Address - Fax:937-641-3066
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0779032084P0800X
OH35.0779032084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2195253Medicaid