Provider Demographics
NPI:1861718520
Name:BLAYLOCK-SOLAR, DE-ANDREA (MSW, LCSW, CST)
Entity type:Individual
Prefix:MRS
First Name:DE-ANDREA
Middle Name:
Last Name:BLAYLOCK-SOLAR
Suffix:
Gender:F
Credentials:MSW, LCSW, CST
Other - Prefix:MRS
Other - First Name:DE-ANDREA
Other - Middle Name:LESLIE
Other - Last Name:BLAYLOCK-JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9666 OLIVE BLVD STE 330
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3035
Mailing Address - Country:US
Mailing Address - Phone:314-877-8510
Mailing Address - Fax:
Practice Address - Street 1:9666 OLIVE BLVD STE 330
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3035
Practice Address - Country:US
Practice Address - Phone:314-877-8510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100063071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical