Healthcare Provider Details

I. General information

NPI: 1447728050
Provider Name (Legal Business Name): LAURELLE S BLAIR LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 MARTIN LUTHER KING JR AVE SE STE 234
WASHINGTON DC
20020-7026
US

IV. Provider business mailing address

2917 N CALVERT ST APT 1FR
BALTIMORE MD
21218-4182
US

V. Phone/Fax

Practice location:
  • Phone: 202-610-0066
  • Fax: 202-610-0669
Mailing address:
  • Phone: 202-352-5635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50081947
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: