Healthcare Provider Details

I. General information

NPI: 1730979865
Provider Name (Legal Business Name): EMILY BLAZIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 NORTHLAND DR NE STE D
GRAND RAPIDS MI
49525-1096
US

IV. Provider business mailing address

3794 ALDEN NASH AVE NE
LOWELL MI
49331-8592
US

V. Phone/Fax

Practice location:
  • Phone: 503-314-8045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: EMILY BLAZIC
Title or Position: AUTHORIZED OFFICIAL
Credential: LMSW
Phone: 503-314-8045