Provider Demographics
NPI:1003280777
Name:BLAZEK, MATTHEW JAMES (BCBA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:BLAZEK
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BAR HARBOR TER
Mailing Address - Street 2:
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414-1216
Mailing Address - Country:US
Mailing Address - Phone:415-990-3608
Mailing Address - Fax:
Practice Address - Street 1:42 BAR HARBOR TER
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-1216
Practice Address - Country:US
Practice Address - Phone:415-990-3608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst