Provider Demographics
NPI:1790475705
Name:BRAZIER, BLANE
Entity Type:Individual
Prefix:
First Name:BLANE
Middle Name:
Last Name:BRAZIER
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 1:1808 SERENADE LN
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-4763
Mailing Address - Country:US
Mailing Address - Phone:469-834-5115
Mailing Address - Fax:
Practice Address - Street 1:8604 GREENVILLE AVE STE 201
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-7148
Practice Address - Country:US
Practice Address - Phone:469-834-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX87756101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health