Provider Demographics
NPI:1821279043
Name:PENNY BLAZEJ LICENSED CLINICAL SOCIAL WORKER PROF CORP
Entity Type:Organization
Organization Name:PENNY BLAZEJ LICENSED CLINICAL SOCIAL WORKER PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:BLAZEJ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW BCD
Authorized Official - Phone:760-685-3403
Mailing Address - Street 1:28714 VALLEY CENTER ROAD
Mailing Address - Street 2:SUITE E
Mailing Address - City:VALLEY CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92082
Mailing Address - Country:US
Mailing Address - Phone:760-685-3403
Mailing Address - Fax:760-751-8650
Practice Address - Street 1:28714 VALLEY CENTER ROAD
Practice Address - Street 2:SUITE E
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082
Practice Address - Country:US
Practice Address - Phone:760-685-3403
Practice Address - Fax:760-751-8650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENNY BLAZEJ LICENSED CLINICAL SOCIAL WORKER PROF CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA215701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LC5215700OtherBLUE CROSS BLUE SHIELD
CAW19512Medicare PIN
LC5215700OtherBLUE CROSS BLUE SHIELD