Amy M Blake, MSW, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

2003012111 Issued in MO

Practice address

980 Parkside Village LN
Osage Beach, MO 65065-3098

Phone

(884) 031-0718

Fax

(573) 302-7369

NPI assigned

Dec 9, 2005

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Amy M Dieckman Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1134086400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1616630400000",
    "number": "1164407367",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1800 COMMUNITY",
            "city": "CLINTON",
            "state": "MO",
            "postal_code": "647358804",
            "telephone_number": "660-885-8131"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "980 PARKSIDE VILLAGE LN",
            "city": "OSAGE BEACH",
            "state": "MO",
            "postal_code": "650653098",
            "telephone_number": "884-031-0718",
            "fax_number": "573-302-7369"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLAKE",
        "first_name": "AMY",
        "middle_name": "M",
        "credential": "MSW, LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-12-09",
        "last_updated": "2021-03-25",
        "certification_date": "2021-03-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MO",
            "license": "2003012111",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "498800705",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "AMY",
            "last_name": "DIECKMAN",
            "middle_name": "M",
            "credential": "MSW",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• David N Bergthold, MSN-ACNP
• Maria E. Bernabe, M.D.
• Terry L. Berry, D.O.
• Ellen Barbara Binder-Jones
• Megan Emily Blackford, PLPC
• Lori R Blount, PLPC
• Mary Elizabeth Bohon, FNP-BC
• Christopher John Boillot, CPHT
• Adam M Boone, CRNA
• Miriam B. Borden, M.D.

• All providers in Osage Beach, MO
• Clinical Social Worker in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.