Provider Demographics
NPI:1346209855
Name:VANBLAIR, KATHERINE JEAN (PHD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JEAN
Last Name:VANBLAIR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:JEAN
Other - Last Name:MICHELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2102 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:HI
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-359-4049
Mailing Address - Fax:
Practice Address - Street 1:2102 E 38TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:HI
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-359-4049
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IALMFT00166106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1108750000Medicaid