Provider Demographics
NPI:1609370329
Name:BLATZ, CARISSA (LSW)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:BLATZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 W FORK RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-1944
Mailing Address - Country:US
Mailing Address - Phone:513-619-2913
Mailing Address - Fax:
Practice Address - Street 1:3030 W FORK RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-1944
Practice Address - Country:US
Practice Address - Phone:513-619-2913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1502481104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker