Provider Demographics
NPI:1609179100
Name:BLAKE, MARLA M (BSW, MA, LSW)
Entity Type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:F
Credentials:BSW, MA, LSW
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:M
Other - Last Name:SERAFINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 EOFF ST
Mailing Address - Street 2:SUITE 704
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3823
Mailing Address - Country:US
Mailing Address - Phone:304-234-8596
Mailing Address - Fax:
Practice Address - Street 1:2000 EOFF ST
Practice Address - Street 2:SUITE 704
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3823
Practice Address - Country:US
Practice Address - Phone:304-234-8596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP02943399104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0115328000Medicaid