Healthcare Provider Details

I. General information

NPI: 1740356625
Provider Name (Legal Business Name): JEFFREY IRA BLAU MSW LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 MORGAN HIGHWAY CHARLES LUGER BLDG
SCRANTON PA
18508
US

IV. Provider business mailing address

217 WEST GROVE STREET
CLARKS SUMMIT PA
18411
US

V. Phone/Fax

Practice location:
  • Phone: 570-207-7919
  • Fax: 570-963-1953
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW014412
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierBL603478
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerFEDERAL BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: