Provider Demographics
NPI:1295335800
Name:STUCKEY, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:STUCKEY
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 1:1750 ANSEL RD APT 511
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-4103
Mailing Address - Country:US
Mailing Address - Phone:717-495-6961
Mailing Address - Fax:
Practice Address - Street 1:1750 ANSEL RD APT 511
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4103
Practice Address - Country:US
Practice Address - Phone:717-495-6961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.20052621041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool