Provider Demographics
NPI:1588978498
Name:HUBER, BLAZE B
Entity type:Individual
Prefix:MR
First Name:BLAZE
Middle Name:B
Last Name:HUBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101A VALLEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7994
Mailing Address - Country:US
Mailing Address - Phone:512-913-4743
Mailing Address - Fax:
Practice Address - Street 1:900 CONGRESS AVE
Practice Address - Street 2:STE L-VAULTS
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2437
Practice Address - Country:US
Practice Address - Phone:512-467-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2074248225200000X
TXMT046366225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist