Provider Demographics
NPI:1083743199
Name:BLATT, HOLLIS (MSW, LISW)
Entity Type:Individual
Prefix:
First Name:HOLLIS
Middle Name:
Last Name:BLATT
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11930 MENAUL BLVD NE STE 225C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2465
Mailing Address - Country:US
Mailing Address - Phone:505-323-4447
Mailing Address - Fax:505-323-5075
Practice Address - Street 1:11930 MENAUL BLVD NE STE 225C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2465
Practice Address - Country:US
Practice Address - Phone:505-323-4447
Practice Address - Fax:505-323-5075
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-059501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51437775Medicaid