Provider Demographics
NPI:1619026390
Name:HAMILTON, BLAKE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W BELMONT AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3240
Mailing Address - Country:US
Mailing Address - Phone:773-880-2317
Mailing Address - Fax:
Practice Address - Street 1:1300 W BELMONT AVE STE 211
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3240
Practice Address - Country:US
Practice Address - Phone:773-880-2317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490121431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL600074695OtherMAGELLIAN
IL591278OtherVALUE OPTIONS
IL01636966OtherBLUECROSS- BLUE SHIELD
IL600074695OtherMAGELLIAN