Provider Demographics
NPI:1578140935
Name:BLAZEK, BRIAN J (MS BCBA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:BLAZEK
Suffix:
Gender:M
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 W BELLE PLAINE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1815
Mailing Address - Country:US
Mailing Address - Phone:630-709-7828
Mailing Address - Fax:
Practice Address - Street 1:8707 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2269
Practice Address - Country:US
Practice Address - Phone:770-880-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst