Provider Demographics
NPI:1356913438
Name:BLAGSVEDT, COREY (RBT)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:BLAGSVEDT
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 AZALEA DR, MYRTLE BEACH
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH, SC
Mailing Address - State:SC
Mailing Address - Zip Code:29575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2413 SAVANNAH HWY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5323
Practice Address - Country:US
Practice Address - Phone:843-449-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17-38371103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE