Provider Demographics
NPI:1629507561
Name:BLAZER, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BLAZER
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 1:6597 GARDEN PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN PRAIRIE
Mailing Address - State:IL
Mailing Address - Zip Code:61038-9769
Mailing Address - Country:US
Mailing Address - Phone:815-298-9516
Mailing Address - Fax:
Practice Address - Street 1:631 S 1ST ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4117
Practice Address - Country:US
Practice Address - Phone:815-756-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health