Provider Demographics
NPI:1114003381
Name:BLAZEK, THERESA M (LCPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:BLAZEK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51232
Mailing Address - Street 2:YELLOWSTONE BILLING SERVICES
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105
Mailing Address - Country:US
Mailing Address - Phone:406-245-0453
Mailing Address - Fax:406-245-7257
Practice Address - Street 1:208 N BROADWAY
Practice Address - Street 2:STE 423 YELLOWSTONE COUNSELING CENTER
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101
Practice Address - Country:US
Practice Address - Phone:406-896-8427
Practice Address - Fax:406-245-5980
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1150101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0256955Medicaid