=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134731102
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKI ARLENE BLAIZE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2020
-----------------------------------------------------
Last Update Date | 10/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1617 25TH AVE # 203
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39501-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-325-5855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7707
-----------------------------------------------------
City | DIBERVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39540-7602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-325-5855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW.09929625
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C8095
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------