Provider Demographics
NPI:1265890065
Name:BLAKE, LAURENE MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:LAURENE
Middle Name:MARIE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAURENE
Other - Middle Name:M
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSWC
Mailing Address - Street 1:6665 SECURITY BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODLAWN
Mailing Address - State:MD
Mailing Address - Zip Code:21207-4018
Mailing Address - Country:US
Mailing Address - Phone:410-265-7291
Mailing Address - Fax:410-265-7294
Practice Address - Street 1:6665 SECURITY BLVD
Practice Address - Street 2:
Practice Address - City:WOODLAWN
Practice Address - State:MD
Practice Address - Zip Code:21207-4018
Practice Address - Country:US
Practice Address - Phone:410-265-7291
Practice Address - Fax:410-265-7294
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06441104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker