Provider Demographics
NPI:1083638712
Name:BLAKE-SHORTER, KAROLE DENISE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KAROLE
Middle Name:DENISE
Last Name:BLAKE-SHORTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 POPLAR AVE
Mailing Address - Street 2:SUITE 324
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-3851
Mailing Address - Country:US
Mailing Address - Phone:901-324-0686
Mailing Address - Fax:901-324-0688
Practice Address - Street 1:2600 POPLAR AVE
Practice Address - Street 2:SUITE 324
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-3851
Practice Address - Country:US
Practice Address - Phone:901-324-0686
Practice Address - Fax:901-324-0688
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3699154Medicaid
TN3699154Medicaid