Provider Demographics
NPI:1457030165
Name:BLEA, MICHAEL E
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:BLEA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 ELLA LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051-5433
Mailing Address - Country:US
Mailing Address - Phone:815-995-0306
Mailing Address - Fax:
Practice Address - Street 1:4210 ELLA LN
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60051-5433
Practice Address - Country:US
Practice Address - Phone:815-995-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0262041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty