Basic Information
Provider Information
NPI: 1003012139
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLIZEK
FirstName: MONICA
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: LIMHP, CMSW, LADC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 8502 MORMON BRIDGE RD
Address2:  
City: OMAHA
State: NE
PostalCode: 681521929
CountryCode: US
TelephoneNumber: 4029918509
FaxNumber: 4024557050
Practice Location
Address1: 8502 MORMON BRIDGE RD
Address2:  
City: OMAHA
State: NE
PostalCode: 681521929
CountryCode: US
TelephoneNumber: 4029918509
FaxNumber: 4024557050
Other Information
ProviderEnumerationDate: 06/25/2007
LastUpdateDate: 08/26/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400XLADC 824NEY Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YM0800XLIMHP 473NEN Behavioral Health & Social Service ProvidersCounselorMental Health

ID Information
IDTypeStateIssuerDescription
8214601NEBLUE CROSS BLUE SHIELDOTHER
34883300001NEMAGELLAN MANAGED CAREOTHER


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