Provider Demographics
NPI:1316116171
Name:BLAKELY, VIDA LORRAINE (MFTT)
Entity type:Individual
Prefix:MS
First Name:VIDA
Middle Name:LORRAINE
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:MFTT
Other - Prefix:MRS
Other - First Name:VIDA
Other - Middle Name:LORRAINE
Other - Last Name:HARVEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1227 COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-6700
Mailing Address - Country:US
Mailing Address - Phone:510-828-3037
Mailing Address - Fax:209-629-8790
Practice Address - Street 1:1700 MCHENRY VILLAGE WAY
Practice Address - Street 2:SUITE11
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4308
Practice Address - Country:US
Practice Address - Phone:209-526-1476
Practice Address - Fax:209-526-0908
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program