Provider Demographics
NPI:1073987814
Name:BLAD, CORY (LMSW)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:BLAD
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 E 25TH ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7519
Mailing Address - Country:US
Mailing Address - Phone:208-991-4296
Mailing Address - Fax:208-261-1922
Practice Address - Street 1:2235 E 25TH ST
Practice Address - Street 2:SUITE 190
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7519
Practice Address - Country:US
Practice Address - Phone:208-991-4296
Practice Address - Fax:208-261-1922
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW 352811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical