Provider Demographics
NPI:1447903273
Name:BLAISE, LOUNISE (BCBA)
Entity type:Individual
Prefix:
First Name:LOUNISE
Middle Name:
Last Name:BLAISE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5424 SW 43RD TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-6710
Mailing Address - Country:US
Mailing Address - Phone:305-803-6897
Mailing Address - Fax:
Practice Address - Street 1:5424 SW 43RD TER
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33314-6710
Practice Address - Country:US
Practice Address - Phone:305-803-6897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FL1-22-58941103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician