Provider Demographics
NPI:1396054193
Name:BLAKLEY, GLORIA CLEMENCIA (MA-CMHC-CABA)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:CLEMENCIA
Last Name:BLAKLEY
Suffix:
Gender:F
Credentials:MA-CMHC-CABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8595 TANSY DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-4512
Mailing Address - Country:US
Mailing Address - Phone:321-442-6683
Mailing Address - Fax:
Practice Address - Street 1:315 N LAKEMONT AVE STE B
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3205
Practice Address - Country:US
Practice Address - Phone:407-830-6412
Practice Address - Fax:407-830-8413
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLCC05002101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional