Provider Demographics
NPI:1467792697
Name:DR BLAKE BAZEL PHD PA
Entity Type:Organization
Organization Name:DR BLAKE BAZEL PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-272-0043
Mailing Address - Street 1:1677 WELLS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-6799
Mailing Address - Country:US
Mailing Address - Phone:904-272-0043
Mailing Address - Fax:
Practice Address - Street 1:1677 WELLS RD
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-6799
Practice Address - Country:US
Practice Address - Phone:904-272-0043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 8593103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty