Provider Demographics
NPI:1164407367
Name:BLAKE, AMY M (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:DIECKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:980 PARKSIDE VILLAGE LN
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3098
Practice Address - Country:US
Practice Address - Phone:884-031-0718
Practice Address - Fax:573-302-7369
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030121111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498800705Medicaid