1114003381 NPI number — THERESA M BLAZEK LCPC

Table of content: THERESA M BLAZEK LCPC (NPI 1114003381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114003381 NPI number — THERESA M BLAZEK LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAZEK
Provider First Name:
THERESA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114003381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51232
Provider Second Line Business Mailing Address:
YELLOWSTONE BILLING SERVICES
Provider Business Mailing Address City Name:
BILLINGS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-245-0453
Provider Business Mailing Address Fax Number:
406-245-7257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 N BROADWAY
Provider Second Line Business Practice Location Address:
STE 423 YELLOWSTONE COUNSELING CENTER
Provider Business Practice Location Address City Name:
BILLINGS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-896-8427
Provider Business Practice Location Address Fax Number:
406-245-5980
Provider Enumeration Date:
10/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  1150 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0256955 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".