Provider Demographics
NPI:1316936529
Name:BLAZEJ, PENNY ANNETTE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:ANNETTE
Last Name:BLAZEJ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 E. THIRD AVE, SUITE 201
Mailing Address - Street 2:VALLEY CENTER COUNSELING, INC.
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4254
Mailing Address - Country:US
Mailing Address - Phone:760-685-3403
Mailing Address - Fax:760-751-8650
Practice Address - Street 1:127 E 3RD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4254
Practice Address - Country:US
Practice Address - Phone:760-685-3403
Practice Address - Fax:760-751-8650
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA215701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19512Medicare PIN