Basic Information
| Provider Information | |||||||||
| NPI: | 1003012139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLIZEK | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LIMHP, CMSW, LADC | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LADC 824 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | LIMHP 473 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 348833000 | 01 | NE | MAGELLAN MANAGED CARE | OTHER | 82146 | 01 | NE | BLUE CROSS BLUE SHIELD | OTHER |