Provider Demographics
NPI:1407356967
Name:BLAIR, MARY ANGELA (SUDP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANGELA
Last Name:BLAIR
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:253-681-6626
Mailing Address - Fax:425-747-8348
Practice Address - Street 1:113 23RD AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2309
Practice Address - Country:US
Practice Address - Phone:062-195-9802
Practice Address - Fax:206-812-6161
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60639393101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)