Provider Demographics
NPI:1376977546
Name:BLAZEK, MEGAN (LCPC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
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 1:18859 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2536
Mailing Address - Country:US
Mailing Address - Phone:773-807-1590
Mailing Address - Fax:
Practice Address - Street 1:18859 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2536
Practice Address - Country:US
Practice Address - Phone:773-807-1590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-24
Last Update Date:2013-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008739101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional