Provider Demographics
NPI:1346578598
Name:BLAIR, MELISSA KAY (PHD)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:KAY
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14041 FM 773
Mailing Address - Street 2:
Mailing Address - City:BEN WHEELER
Mailing Address - State:TX
Mailing Address - Zip Code:75754-6011
Mailing Address - Country:US
Mailing Address - Phone:903-243-2796
Mailing Address - Fax:903-833-9290
Practice Address - Street 1:14041 FM 773
Practice Address - Street 2:
Practice Address - City:BEN WHEELER
Practice Address - State:TX
Practice Address - Zip Code:75754-6011
Practice Address - Country:US
Practice Address - Phone:903-243-2796
Practice Address - Fax:903-833-9290
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18403172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX18403OtherSTATE LICENCE