Healthcare Provider Details

I. General information

NPI: 1114439734
Provider Name (Legal Business Name): NIKOLE EVANS BLAKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2017
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1891 SANTA BARBARA DR STE 102
LANCASTER PA
17601-4106
US

IV. Provider business mailing address

763 DEAVER RD
QUARRYVILLE PA
17566-9259
US

V. Phone/Fax

Practice location:
  • Phone: 717-936-9758
  • Fax:
Mailing address:
  • Phone: 717-799-3180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW134782
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW024587
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: