Provider Demographics
NPI:1407537343
Name:BAZI, DEMETRIC
Entity type:Individual
Prefix:
First Name:DEMETRIC
Middle Name:
Last Name:BAZI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 WARE AVE # 156
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1656 WARE AVE # 156
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3133
Practice Address - Country:US
Practice Address - Phone:470-457-2623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-25
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Yes291U00000XLaboratoriesClinical Medical Laboratory
No173F00000XOther Service ProvidersSleep Specialist, PhD
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor