Provider Demographics
NPI:1134731102
Name:BLAIZE, VICKI ARLENE (LCSW)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:ARLENE
Last Name:BLAIZE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7707
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-7602
Mailing Address - Country:US
Mailing Address - Phone:228-325-5855
Mailing Address - Fax:
Practice Address - Street 1:1617 25TH AVE # 203
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2834
Practice Address - Country:US
Practice Address - Phone:228-325-5855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099296251041C0700X
MSC80951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty