Provider Demographics
NPI:1033272216
Name:BLAIR, ELIZABETH DALE (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DALE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 NORTH PROVIDENCE ROAD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063
Mailing Address - Country:US
Mailing Address - Phone:610-565-1129
Mailing Address - Fax:
Practice Address - Street 1:280 NORTH PROVIDENCE ROAD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063
Practice Address - Country:US
Practice Address - Phone:610-565-1129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2013-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS0033762103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA280714000Medicaid
PA280714000Medicaid