Provider Demographics
NPI:1740356625
Name:BLAU, JEFFREY IRA (MSW LCSW)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:IRA
Last Name:BLAU
Suffix:
Gender:M
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 WEST GROVE STREET
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 MORGAN HIGHWAY
Practice Address - Street 2:CHARLES LUGER BLDG
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508
Practice Address - Country:US
Practice Address - Phone:570-207-7919
Practice Address - Fax:570-963-1953
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0144121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABL603478OtherFEDERAL BLUE SHIELD