MEDICARE: DR. BONITA BLAZER PH.D

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1740494616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONITA BLAZER PH.D

Provider Business Mailing Address
First Line	:	302 N WASHINGTON AVE
Second Line	:	STE 202 - EAST BUILDING
City	:	MOORESTOWN
State	:	NJ
Zip	:	08057-2448
Country	:	US
Telephone Number	:	856-234-1270
Fax Number	:	856-234-0632

Provider Business Practice Location Address
First Line	:	302 N WASHINGTON AVE
Second Line	:	STE 202 - EAST BUILDING
City	:	MOORESTOWN
State	:	NJ
Zip	:	08057-2448
Country	:	US
Telephone Number	:	856-234-1270
Fax Number	:	856-234-0632

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

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	07/08/2007

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