Provider Demographics
NPI:1003338617
Name:BLAZIO, STACY
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:BLAZIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-4121
Mailing Address - Country:US
Mailing Address - Phone:504-304-3737
Mailing Address - Fax:
Practice Address - Street 1:401 W MORRIS AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403
Practice Address - Country:US
Practice Address - Phone:567-000-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
101YM0800X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health