Provider Demographics
NPI:1740252840
Name:BLAZEY, JANICE KAY (MPT)
Entity type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:KAY
Last Name:BLAZEY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 REVIVAL ROW
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8959
Mailing Address - Country:US
Mailing Address - Phone:757-639-5653
Mailing Address - Fax:
Practice Address - Street 1:3541 RANDOLPH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1082
Practice Address - Country:US
Practice Address - Phone:704-323-2520
Practice Address - Fax:704-323-2501
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8438225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2312769Medicare PIN
NC0397730007Medicare NSC