Provider Demographics
NPI:1124633078
Name:BLAU, TAMARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:BLAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 QUAIL RUN LN
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22923-1923
Mailing Address - Country:US
Mailing Address - Phone:216-702-4157
Mailing Address - Fax:
Practice Address - Street 1:2120 QUAIL RUN LN
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22923-1923
Practice Address - Country:US
Practice Address - Phone:216-702-4157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0008186-SUPV1041C0700X
VA09040100191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical