Provider Demographics
NPI:1750543211
Name:BLASDEL, AMY ELISA (LSCSW)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELISA
Last Name:BLASDEL
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:ELISA
Other - Last Name:EPPERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10118 W WESTPORT CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-6716
Mailing Address - Country:US
Mailing Address - Phone:316-393-6919
Mailing Address - Fax:
Practice Address - Street 1:6700 W CENTRAL AVE STE 106
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212
Practice Address - Country:US
Practice Address - Phone:316-945-5200
Practice Address - Fax:316-945-5549
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS40761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200565090BMedicaid