Provider Demographics
NPI:1760812853
Name:BLAZINA, LORA (LPC, MHSP)
Entity type:Individual
Prefix:MRS
First Name:LORA
Middle Name:
Last Name:BLAZINA
Suffix:
Gender:F
Credentials:LPC, MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1602
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-1602
Mailing Address - Country:US
Mailing Address - Phone:505-382-9742
Mailing Address - Fax:
Practice Address - Street 1:12760 SAN RAFAEL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-1133
Practice Address - Country:US
Practice Address - Phone:505-382-9742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3074101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional