Provider Demographics
NPI:1538694393
Name:BLAZER, BRADLEY (LMT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BLAZER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:LYLE
Mailing Address - State:WA
Mailing Address - Zip Code:98635-9046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 5TH ST
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-2058
Practice Address - Country:US
Practice Address - Phone:541-490-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23208225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist