Provider Demographics
NPI:1396256665
Name:BLAKELEY, MICHELLE M (MFT-INTERN, CPC-INTE)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:BLAKELEY
Suffix:
Gender:F
Credentials:MFT-INTERN, CPC-INTE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 ASHBY HILLS CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-4451
Mailing Address - Country:US
Mailing Address - Phone:702-907-8306
Mailing Address - Fax:
Practice Address - Street 1:311 S WATER ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7310
Practice Address - Country:US
Practice Address - Phone:702-907-8306
Practice Address - Fax:702-907-8306
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI0230101YM0800X
NVMI0737106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health