Provider Demographics
NPI:1790960045
Name:THOMAS, BLAKE REAGAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BLAKE
Middle Name:REAGAN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:BLAKE
Other - Middle Name:THOMAS
Other - Last Name:WITTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2005 ROBIN TER
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1543
Mailing Address - Country:US
Mailing Address - Phone:847-970-1533
Mailing Address - Fax:
Practice Address - Street 1:2005 ROBIN TER
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-1543
Practice Address - Country:US
Practice Address - Phone:573-864-1533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060329141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2006032914OtherPROVISIONAL LICENSE