Provider Demographics
NPI:1396211629
Name:BLAINE, MAISIE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MAISIE
Middle Name:
Last Name:BLAINE
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28361 SUNSET POINT RD
Mailing Address - Street 2:
Mailing Address - City:COHASSET
Mailing Address - State:MN
Mailing Address - Zip Code:55721-2044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28361 SUNSET POINT RD
Practice Address - Street 2:
Practice Address - City:COHASSET
Practice Address - State:MN
Practice Address - Zip Code:55721-2044
Practice Address - Country:US
Practice Address - Phone:218-301-9650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-13
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN173691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical