Provider Demographics
NPI:1407593908
Name:BLAINE, HAYDEN (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:HAYDEN
Middle Name:
Last Name:BLAINE
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 TONY TANK LN APT 301
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3852
Mailing Address - Country:US
Mailing Address - Phone:910-740-7608
Mailing Address - Fax:
Practice Address - Street 1:1415 W NC HIGHWAY 54 STE 213
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5578
Practice Address - Country:US
Practice Address - Phone:910-740-7608
Practice Address - Fax:919-294-4357
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0149931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical