=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730979865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMILY BLAZIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2025
-----------------------------------------------------
Last Update Date | 06/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5250 NORTHLAND DR NE STE D
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-1096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-314-8045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3794 ALDEN NASH AVE NE
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49331-8592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | EMILY BLAZIC
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 503-314-8045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------