Provider Demographics
NPI:1013560614
Name:BLAYLOCK, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 OLD HENDERSON RD STE N271
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3626
Mailing Address - Country:US
Mailing Address - Phone:614-456-7334
Mailing Address - Fax:
Practice Address - Street 1:1550 OLD HENDERSON RD STE N271
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3626
Practice Address - Country:US
Practice Address - Phone:614-456-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator