Provider Demographics
NPI:1720351513
Name:BLAKESLEY, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BLAKESLEY
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 1:4819 WHITEHALL BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2636
Mailing Address - Country:US
Mailing Address - Phone:318-561-6400
Mailing Address - Fax:
Practice Address - Street 1:4819 WHITEHALL BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2636
Practice Address - Country:US
Practice Address - Phone:318-561-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist