Provider Demographics
NPI:1114439734
Name:BLAKE, NIKOLE EVANS (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NIKOLE
Middle Name:EVANS
Last Name:BLAKE
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 1:763 DEAVER RD
Mailing Address - Street 2:
Mailing Address - City:QUARRYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17566-9259
Mailing Address - Country:US
Mailing Address - Phone:717-799-3180
Mailing Address - Fax:
Practice Address - Street 1:1891 SANTA BARBARA DR STE 102
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4106
Practice Address - Country:US
Practice Address - Phone:717-936-9758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-05
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0245871041C0700X
PASW134782104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker