MEDICARE: BIANCA ROSE BLAZER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1760764443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BIANCA ROSE BLAZER

Provider Business Mailing Address
First Line	:	2615 W GARY AVE
Second Line	:	#1009
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6472
Country	:	US
Telephone Number	:	702-481-5094
Fax Number	:

Provider Business Practice Location Address
First Line	:	2615 W GARY AVE
Second Line	:	#1009
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6472
Country	:	US
Telephone Number	:	702-481-5094
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2011
Last Update Date	:	09/22/2011

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Directions to “ BIANCA ROSE BLAZER ” Practice Location

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