Provider Demographics
NPI:1063854958
Name:BLAKE, JEANINE MARIE-BYRNE (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:MARIE-BYRNE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6802 MCCLEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-7260
Mailing Address - Country:US
Mailing Address - Phone:410-570-6661
Mailing Address - Fax:
Practice Address - Street 1:6802 MCCLEAN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234-7260
Practice Address - Country:US
Practice Address - Phone:410-570-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD127371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical