Provider Demographics
NPI:1649563149
Name:BLAZONIN-NIEMI, CINDY (COTA)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:
Last Name:BLAZONIN-NIEMI
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 W LARCH ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-2721
Mailing Address - Country:US
Mailing Address - Phone:906-364-0194
Mailing Address - Fax:
Practice Address - Street 1:N10504 GRANDVIEW LN
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-9621
Practice Address - Country:US
Practice Address - Phone:906-932-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1766-027224Z00000X
MI5202005723224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant