Provider Demographics
NPI:1588716963
Name:WHITE BLAKESLEY, AMY M (PSYD)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:M
Last Name:WHITE BLAKESLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MADHUSUDAN
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:402 S KANSAS
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720
Mailing Address - Country:US
Mailing Address - Phone:620-431-7890
Mailing Address - Fax:620-431-7927
Practice Address - Street 1:402 S KANSAS
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720
Practice Address - Country:US
Practice Address - Phone:620-431-7890
Practice Address - Fax:620-431-7927
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP11450103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS119749OtherBLUE SHIELD
KS119749Medicare ID - Type Unspecified