MEDICARE: DR. SUZANNE BLAISING PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW.09927800	CO
2	1041C0700X	Clinical Social Worker	LCSW103433	CA
3	1041C0700X	Clinical Social Worker	SW18447	FL
4	1041C0700X	Clinical Social Worker	149009149	IL

General Provider Information

NPI Number	:	1538344668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUZANNE BLAISING PHD

Provider Business Mailing Address
First Line	:	456 QUINBY ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-4933
Country	:	US
Telephone Number	:	312-944-3565
Fax Number	:

Provider Business Practice Location Address
First Line	:	2620 E PROSPECT RD STE 190
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-9098
Country	:	US
Telephone Number	:	312-944-3565
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2008
Last Update Date	:	12/30/2021

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