Provider Demographics
NPI:1669944575
Name:BLAKE, OTIA
Entity type:Individual
Prefix:
First Name:OTIA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:OTIA
Other - Middle Name:T
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LMSW
Mailing Address - Street 1:7911 FREETOWN RD
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-8207
Mailing Address - Country:US
Mailing Address - Phone:410-978-9770
Mailing Address - Fax:
Practice Address - Street 1:3030 GREENMOUNT AVE STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-6907
Practice Address - Country:US
Practice Address - Phone:410-978-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD276671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical