Amanda Marie Blake, LICSW, MSSW
Individual provider Active NPI Clinical Social Worker · Grand Forks, ND
NPI 1174773469 · NPPES record last updated Oct 31, 2022
Key facts
- NPI
- 1174773469
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Clinical Social Worker 1041C0700X
- License
- 4753 (ND)
- Practice address
- 2808 17TH Ave S
Grand Forks, ND 58201-4010 - Phone
- (701) 738-8363
- NPI assigned
- Sep 24, 2008
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare Care Compare profile
- Specialty
- Clinical Social Worker
- Education
- Other, 2002
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Telehealth
- Offers telehealth services
- Group practices
- Lipp Carlson Witucki and Associates LTD
Practice addresses (Care Compare)
2808 17TH Ave S
Grand Forks, ND 58201-4010
Phone (701) 746-8376
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ND
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20171010002901 | ND | Practitioner - Clinical Social Worker | 7810262243 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 50864 | TX | MD | Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Lipp, Carlson, Witucki & Associates, LTD | Current |
Accepting new patients |
Locations
2808 17th Ave S
Grand Forks, ND 58201
Phone (701) 746-8376
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Social Worker | 104100000X | 4753 | ND | |
| Social Worker | 104100000X | 50864 | TX | |
| Clinical Social Worker | 1041C0700X | 4753 | ND | Yes |
Addresses
Primary practice location
2808 17TH Ave S
Grand Forks, ND 58201-4010
Mailing address
2808 17TH Ave S
Grand Forks, ND 58201-4010
Phone (701) 746-8376
Other practice location 1
412 DeMers Ave
Grand Forks, ND 58201-4508
Phone (701) 787-7728
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1464225 | Medicaid | ND |
Other names
- Amanda Jimenez
Other providers in Grand Forks, ND
- Tara L Bjugstad
- Leah Bjur
- Ashley Black
- Bonnie Lou Black
- Fredric Lee Black
- Drew Michael Blake
- Blended Pathways Therapy, PLLC
- Blessed Hands Homecare LLC
- Blessed Home Care
- Krista Mae Block
All providers in Grand Forks, ND · Clinical Social Worker in North Dakota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 31, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.