Provider Demographics
NPI:1306384920
Name:BAZELAIS, MAX
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:BAZELAIS
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 1:33 EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-1101
Mailing Address - Country:US
Mailing Address - Phone:617-669-2527
Mailing Address - Fax:
Practice Address - Street 1:33 EVERETT ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149
Practice Address - Country:US
Practice Address - Phone:617-669-2527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst