Healthcare Provider Details

I. General information

NPI: 1497736086
Provider Name (Legal Business Name): BARBARA J. BLASZAK M.A. , B.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E MAIN ST SUITE 2
MEDFORD OR
97501-6048
US

IV. Provider business mailing address

107 E MAIN ST
MEDFORD OR
97501-6022
US

V. Phone/Fax

Practice location:
  • Phone: 541-773-4074
  • Fax:
Mailing address:
  • Phone: 541-773-4074
  • Fax: 541-201-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC 0083 MFT 0038
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: