Provider Demographics
NPI:1205073954
Name:BLAZER, JANET LAVADA (LPC)
Entity type:Individual
Prefix:MRS
First Name:JANET
Middle Name:LAVADA
Last Name:BLAZER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 E SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-3449
Mailing Address - Country:US
Mailing Address - Phone:816-887-0258
Mailing Address - Fax:816-887-0258
Practice Address - Street 1:1103 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-3449
Practice Address - Country:US
Practice Address - Phone:816-887-0258
Practice Address - Fax:816-887-0258
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-17
Last Update Date:2009-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004037128101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497199604Medicaid