Provider Demographics
NPI:1841637063
Name:BAZELAIS, KISHA NICOLE (PHD)
Entity type:Individual
Prefix:DR
First Name:KISHA
Middle Name:NICOLE
Last Name:BAZELAIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9621 W ELM LN
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2328
Mailing Address - Country:US
Mailing Address - Phone:347-743-4392
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH ST N # 8939
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4305
Practice Address - Country:US
Practice Address - Phone:305-676-7347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020128103TC1900X, 103TA0700X
FLPY9272103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging