Healthcare Provider Details

I. General information

NPI: 1407397599
Provider Name (Legal Business Name): TATIANA ASHLEY BAZELAIS LMHC-D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 LOCUST AVE
BABYLON NY
11702-2207
US

IV. Provider business mailing address

16 WILKEN LN
BRENTWOOD NY
11717-7515
US

V. Phone/Fax

Practice location:
  • Phone: 631-683-8072
  • Fax:
Mailing address:
  • Phone: 631-683-8072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number010734
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: