Healthcare Provider Details

I. General information

NPI: 1104998525
Provider Name (Legal Business Name): NANCY A. BLAKE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10524 EUCLID AVE FL 12
CLEVELAND OH
44106-2205
US

IV. Provider business mailing address

10524 EUCLID AVE FL 12
CLEVELAND OH
44106-2205
US

V. Phone/Fax

Practice location:
  • Phone: 216-983-3129
  • Fax: 216-844-2877
Mailing address:
  • Phone: 216-983-3129
  • Fax: 216-844-2877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0009794
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: