Provider Demographics
NPI:1164076113
Name:BLAIR, BRYAN JOSEPH (BCBA)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:JOSEPH
Last Name:BLAIR
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 GRAND AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-2653
Mailing Address - Country:US
Mailing Address - Phone:617-640-1534
Mailing Address - Fax:
Practice Address - Street 1:97 GRAND AVE APT 2D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-2653
Practice Address - Country:US
Practice Address - Phone:617-640-1534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA130103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst