Provider Demographics
NPI:1144562695
Name:BLAZE, JOHN TRAVIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TRAVIS
Last Name:BLAZE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5396 LONGHORN TRL
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9353
Mailing Address - Country:US
Mailing Address - Phone:850-270-7773
Mailing Address - Fax:
Practice Address - Street 1:5396 LONGHORN TRL
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-9353
Practice Address - Country:US
Practice Address - Phone:850-270-7773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9366103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist