Provider Demographics
NPI:1548801004
Name:BLAZINA, AEDAN ORION
Entity Type:Individual
Prefix:
First Name:AEDAN
Middle Name:ORION
Last Name:BLAZINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21600 OXNARD ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-7807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6200 SW ARCTIC DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-9447
Practice Address - Country:US
Practice Address - Phone:503-224-2184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDZI517177H106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician