Provider Demographics
NPI:1316578966
Name:ZIELKE, BLAIRE LEEANNE (LMSW)
Entity Type:Individual
Prefix:
First Name:BLAIRE
Middle Name:LEEANNE
Last Name:ZIELKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7606 RAVENSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5020
Mailing Address - Country:US
Mailing Address - Phone:269-370-0856
Mailing Address - Fax:
Practice Address - Street 1:1430 ALAMO AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2216
Practice Address - Country:US
Practice Address - Phone:609-493-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011023991041C0700X
MI68011078621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical