MEDICARE: STEPHANIE D. BLICK LADAC-II

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1305	TN

General Provider Information

NPI Number	:	1881188753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE D. BLICK LADAC-II

Provider Business Mailing Address
First Line	:	824 RUSSLEO DR
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37209-4430
Country	:	US
Telephone Number	:	407-491-0883
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 DONELSON PIKE STE 108
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37214-2929
Country	:	US
Telephone Number	:	407-491-0883
Fax Number	:

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

Provider Enumeration Date	:	06/14/2018
Last Update Date	:	06/14/2018

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