Provider Demographics
NPI:1730979865
Name:EMILY BLAZIC LLC
Entity type:Organization
Organization Name:EMILY BLAZIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAZIC
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-446-8968
Mailing Address - Street 1:3794 ALDEN NASH AVE NE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-8592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5250 NORTHLAND DR NE STE D
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1096
Practice Address - Country:US
Practice Address - Phone:616-446-8968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty