Provider Demographics
NPI:1639645567
Name:BLALOCK, SUSAN TUTTLE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:TUTTLE
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2195
Mailing Address - Country:US
Mailing Address - Phone:614-443-6155
Mailing Address - Fax:614-444-1482
Practice Address - Street 1:691 S 5TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-2120
Practice Address - Country:US
Practice Address - Phone:644-443-6155
Practice Address - Fax:614-444-1482
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0901041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool