Provider Demographics
NPI:1457671083
Name:BLAZE, SHAWANNA VIDAL
Entity Type:Individual
Prefix:
First Name:SHAWANNA
Middle Name:VIDAL
Last Name:BLAZE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2840 SHADOWBRIAR DR
Mailing Address - Street 2:#1418
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-3268
Mailing Address - Country:US
Mailing Address - Phone:318-572-0189
Mailing Address - Fax:
Practice Address - Street 1:2840 SHADOWBRIAR DR
Practice Address - Street 2:#1418
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-3268
Practice Address - Country:US
Practice Address - Phone:318-572-0189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-05
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107083235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist