Provider Demographics
NPI:1992244230
Name:BLAKESLEE, CORY RYAN
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:RYAN
Last Name:BLAKESLEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10908 GADSTEN WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-5214
Mailing Address - Country:US
Mailing Address - Phone:408-230-3327
Mailing Address - Fax:
Practice Address - Street 1:10908 GADSTEN WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-5214
Practice Address - Country:US
Practice Address - Phone:408-230-3327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-20
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health