Provider Demographics
NPI:1053479428
Name:BLAKE, SUSAN A (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:LAPIERRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:9615 E 148TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4360
Mailing Address - Country:US
Mailing Address - Phone:317-587-0533
Mailing Address - Fax:317-674-0059
Practice Address - Street 1:2020 BROWN ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4218
Practice Address - Country:US
Practice Address - Phone:765-649-8161
Practice Address - Fax:317-674-0059
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100073590Medicaid
IN945920CCCMedicare PIN