Provider Demographics
NPI:1710005483
Name:BLAZICH, ROBERT W (MSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:BLAZICH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3465
Mailing Address - Country:US
Mailing Address - Phone:262-241-7778
Mailing Address - Fax:262-241-1012
Practice Address - Street 1:11501 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3465
Practice Address - Country:US
Practice Address - Phone:262-241-7778
Practice Address - Fax:262-241-1012
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2498-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical