Provider Demographics
NPI:1427336494
Name:BLAKENEY, TERRY
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:
Last Name:BLAKENEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3936 SAVOY CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-0316
Mailing Address - Country:US
Mailing Address - Phone:702-757-5801
Mailing Address - Fax:
Practice Address - Street 1:1200 HARRIS SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89124-7817
Practice Address - Country:US
Practice Address - Phone:702-872-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCADC-I 01197101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV15456189Medicaid