Provider Demographics
NPI:1821293408
Name:NILSON-BLAKE, MARCIA ELAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:ELAINE
Last Name:NILSON-BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 SORENSTAM WAY
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-3561
Mailing Address - Country:US
Mailing Address - Phone:210-843-2687
Mailing Address - Fax:210-433-8826
Practice Address - Street 1:318 SORENSTAM WAY
Practice Address - Street 2:
Practice Address - City:CIBOLO
Practice Address - State:TX
Practice Address - Zip Code:78108-3561
Practice Address - Country:US
Practice Address - Phone:210-843-2687
Practice Address - Fax:210-433-8826
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX155011041C0700X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116609203Medicaid