Provider Demographics
NPI:1174773469
Name:BLAKE, AMANDA MARIE (LICSW, MSSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LICSW, MSSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:JIMENEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, MSSW
Mailing Address - Street 1:2808 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4010
Mailing Address - Country:US
Mailing Address - Phone:701-746-8376
Mailing Address - Fax:
Practice Address - Street 1:2808 17TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4010
Practice Address - Country:US
Practice Address - Phone:701-738-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4753104100000X, 1041C0700X
TX50864104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1464225Medicaid