Provider Demographics
NPI:1225578842
Name:BLAKE, LESLIE D (LSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:D
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2026
Mailing Address - Country:US
Mailing Address - Phone:330-343-3311
Mailing Address - Fax:330-365-3898
Practice Address - Street 1:659 BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2026
Practice Address - Country:US
Practice Address - Phone:330-343-3311
Practice Address - Fax:330-365-3898
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 0030693104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker