Provider Demographics
NPI:1124465802
Name:BAZEMORE-BLUE, DAVIDRA (MSW, LCSW-C)
Entity type:Individual
Prefix:
First Name:DAVIDRA
Middle Name:
Last Name:BAZEMORE-BLUE
Suffix:
Gender:F
Credentials:MSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3261 OLD WASHINGTON RD STE 2020
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3231
Mailing Address - Country:US
Mailing Address - Phone:202-997-6060
Mailing Address - Fax:
Practice Address - Street 1:3200 CRAIN HWY
Practice Address - Street 2:SUITE 203
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4841
Practice Address - Country:US
Practice Address - Phone:240-435-4708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD589561803Medicaid
MD589561802Medicaid
MD589561800Medicaid