1316936529 NPI number — MRS. PENNY ANNETTE BLAZEJ LCSW

Table of content: MRS. PENNY ANNETTE BLAZEJ LCSW (NPI 1316936529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316936529 NPI number — MRS. PENNY ANNETTE BLAZEJ LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAZEJ
Provider First Name:
PENNY
Provider Middle Name:
ANNETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1316936529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 E. THIRD AVE, SUITE 201
Provider Second Line Business Mailing Address:
VALLEY CENTER COUNSELING, INC.
Provider Business Mailing Address City Name:
ESCONDIDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92025-4254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-685-3403
Provider Business Mailing Address Fax Number:
760-751-8650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
127 E 3RD AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ESCONDIDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92025-4254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-685-3403
Provider Business Practice Location Address Fax Number:
760-751-8650
Provider Enumeration Date:
10/19/2005

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: 1041C0700X , with the licence number:  21570 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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