1821279043 NPI number — PENNY BLAZEJ LICENSED CLINICAL SOCIAL WORKER PROF CORP

Table of content: (NPI 1821279043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821279043 NPI number — PENNY BLAZEJ LICENSED CLINICAL SOCIAL WORKER PROF CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENNY BLAZEJ LICENSED CLINICAL SOCIAL WORKER PROF CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1821279043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28714 VALLEY CENTER ROAD
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
VALLEY CENTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92082
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:
28714 VALLEY CENTER ROAD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
VALLEY CENTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92082
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:
11/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLAZEJ
Authorized Official First Name:
PENNY
Authorized Official Middle Name:
ANNETTE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
760-685-3403

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)

  • Identifier: LC5215700 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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