Provider Demographics
NPI:1104066125
Name:BLAZEI, RYAN WALKLING HERNDON (PHD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:WALKLING HERNDON
Last Name:BLAZEI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 KEISLER DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-9320
Mailing Address - Country:US
Mailing Address - Phone:919-720-1452
Mailing Address - Fax:
Practice Address - Street 1:539 KEISLER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-9320
Practice Address - Country:US
Practice Address - Phone:919-720-1452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3701103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical