Healthcare Provider Details

I. General information

NPI: 1003741208
Provider Name (Legal Business Name): LOGAN BLAKE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N WEST ST STE A
EASTON MD
21601-2761
US

IV. Provider business mailing address

418 CROWBERRY CIR
EASTON MD
21601-3376
US

V. Phone/Fax

Practice location:
  • Phone: 443-786-8910
  • Fax:
Mailing address:
  • Phone: 443-786-8910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number25999
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: