Provider Demographics
NPI:1164570305
Name:BLAIR, KATHLEEN P (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:P
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 RIDGE RD W
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-1509
Mailing Address - Country:US
Mailing Address - Phone:585-352-0294
Mailing Address - Fax:
Practice Address - Street 1:85 S UNION ST
Practice Address - Street 2:SUITE 206
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1255
Practice Address - Country:US
Practice Address - Phone:585-755-6205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073504-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01708341Medicaid