Provider Demographics
NPI:1376988501
Name:BLAKEWAY, OLYVER JARRETT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:OLYVER
Middle Name:JARRETT
Last Name:BLAKEWAY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:OLYVER
Other - Middle Name:
Other - Last Name:BLAKEWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:5000 W NATIONAL AVE RM 3100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53295-0001
Mailing Address - Country:US
Mailing Address - Phone:414-384-2000
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW66048101YM0800X, 1041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health