Basic Information
| Provider Information | |||||||||
| NPI: | 1245826809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKELY | ||||||||
| FirstName: | ABBY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99213 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851860 | ||||||||
| FaxNumber: | 6828851396 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 7TH AVE STE 6100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851055 | ||||||||
| FaxNumber: | 6828851062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2020 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 55119 | TX | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.