| Doctor Name: | MS. VIDA LORRAINE BLAKELY |
| NPI Number: | 1316116171 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MFTT |
| License Number: | |
| Business Practice Address: | 1700 Mchenry Village Way Suite11 Modesto, CA - 953504308 |
| Business Phone Number: | 2095261476 |
| Business Fax Number: | 2095260908 |
| Mailing Address: | 1227 Countryside Ln, MANTECA |
| State: | CA |
| Postal Code: | 953376700 |
| Phone Number: | 5108283037 |
| Fax Number: | 2096298790 |
| NPI Enumeration Date: | 02/26/2008 |
| NPI Last Update Date: | 02/26/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |