Provider Demographics
NPI:1588046338
Name:BLAKELY, MARSHA DIANE
Entity type:Individual
Prefix:
First Name:MARSHA
Middle Name:DIANE
Last Name:BLAKELY
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 1:5616 GRANDMOTHER HAT ST
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6467
Mailing Address - Country:US
Mailing Address - Phone:702-274-9540
Mailing Address - Fax:
Practice Address - Street 1:5130 S PECOS RD STE 2B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1248
Practice Address - Country:US
Practice Address - Phone:702-560-5973
Practice Address - Fax:888-753-3302
Is Sole Proprietor?:No
Enumeration Date:2015-06-28
Last Update Date:2015-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)