Provider Demographics
NPI:1003510769
Name:BLAIR, BENJAMIN WILLIAM (R1499800323)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:WILLIAM
Last Name:BLAIR
Suffix:
Gender:M
Credentials:R1499800323
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 STEELE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3127
Mailing Address - Country:US
Mailing Address - Phone:707-576-0818
Mailing Address - Fax:
Practice Address - Street 1:625 STEELE LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3127
Practice Address - Country:US
Practice Address - Phone:707-576-0818
Practice Address - Fax:707-576-7845
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49-02101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)