Provider Demographics
NPI:1679996946
Name:BLAKLEY, STEPHANIE ANN (MA60442130)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:BLAKLEY
Suffix:
Gender:F
Credentials:MA60442130
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 COTTAGE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CASHMERE
Mailing Address - State:WA
Mailing Address - Zip Code:98815-1078
Mailing Address - Country:US
Mailing Address - Phone:509-393-1887
Mailing Address - Fax:
Practice Address - Street 1:101 COTTAGE AVE STE C
Practice Address - Street 2:
Practice Address - City:CASHMERE
Practice Address - State:WA
Practice Address - Zip Code:98815-1078
Practice Address - Country:US
Practice Address - Phone:509-393-1887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60442130225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist