Provider Demographics
NPI:1215413968
Name:BLAKE, CIARA NICOLE (LISW)
Entity Type:Individual
Prefix:
First Name:CIARA
Middle Name:NICOLE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 LITTLE YORK RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-1332
Mailing Address - Country:US
Mailing Address - Phone:937-271-5020
Mailing Address - Fax:
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1983
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.20024901041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical