Provider Demographics
NPI:1457821043
Name:BELLAZIN, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BELLAZIN
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 1:9800 AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8171
Mailing Address - Country:US
Mailing Address - Phone:225-368-7502
Mailing Address - Fax:
Practice Address - Street 1:9800 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8171
Practice Address - Country:US
Practice Address - Phone:225-368-7502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000Medicaid