Provider Demographics
NPI:1235161571
Name:BLAIR, MINA-AYESHA A (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:MINA-AYESHA
Middle Name:A
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 GRATZMAR AVE
Mailing Address - Street 2:
Mailing Address - City:RENOVO
Mailing Address - State:PA
Mailing Address - Zip Code:17764-9507
Mailing Address - Country:US
Mailing Address - Phone:570-858-0046
Mailing Address - Fax:
Practice Address - Street 1:2062 OLD LYCOMING RAOD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701
Practice Address - Country:US
Practice Address - Phone:570-505-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW123316101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)