Provider Demographics
NPI:1699726828
Name:BLAKELY, TERESA JANE (PHD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:JANE
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JANE
Other - Middle Name:THERESA
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:275 E LONGVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1239
Mailing Address - Country:US
Mailing Address - Phone:614-262-8317
Mailing Address - Fax:614-262-5609
Practice Address - Street 1:275 E LONGVIEW AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-1239
Practice Address - Country:US
Practice Address - Phone:614-262-8317
Practice Address - Fax:614-262-5609
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3470103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH401660OtherVALUE OPTIONS PROVIDER ID
OHBLCP12581Medicare PIN