1770768020 NPI number — MRS. SHEILA MARIE BLAZER MS CCCSLP

Table of content: MRS. SHEILA MARIE BLAZER MS CCCSLP (NPI 1770768020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770768020 NPI number — MRS. SHEILA MARIE BLAZER MS CCCSLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAZER
Provider First Name:
SHEILA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS CCCSLP
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:
1770768020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37 BUTCHER COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHEPHERDSTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-876-3739
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NORTH PRESTON STREET
Provider Second Line Business Practice Location Address:
RANSON ELEMENTARY SCHOOL
Provider Business Practice Location Address City Name:
RANSON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-725-7310
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/07/2008

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: 235Z00000X , with the licence number:  4853 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3810005072 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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