Healthcare Provider Details

I. General information

NPI: 1811504897
Provider Name (Legal Business Name): ELIZABETH BLAKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3126 W CARY ST UNIT 114
RICHMOND VA
23221-3504
US

IV. Provider business mailing address

3126 W CARY ST UNIT 114
RICHMOND VA
23221-3504
US

V. Phone/Fax

Practice location:
  • Phone: 276-200-9216
  • Fax:
Mailing address:
  • Phone: 276-200-9216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904015271
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26085
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: