Provider Demographics
NPI:1487904744
Name:BAZEL, BLAKE (PHD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BAZEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1677 WELLS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-6799
Mailing Address - Country:US
Mailing Address - Phone:904-272-0043
Mailing Address - Fax:
Practice Address - Street 1:1677 WELLS RD
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-6799
Practice Address - Country:US
Practice Address - Phone:904-272-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8593103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical