Provider Demographics
NPI:1447206941
Name:BLAIR, C DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:C DAVID
Middle Name:
Last Name:BLAIR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 NITRO MARKET PL # 1018
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25313-4408
Mailing Address - Country:US
Mailing Address - Phone:304-342-8300
Mailing Address - Fax:304-342-8311
Practice Address - Street 1:179 SUMMERS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2163
Practice Address - Country:US
Practice Address - Phone:304-342-8300
Practice Address - Fax:304-342-8311
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV514103G00000X, 103TC0700X, 103TF0200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVBLCP17982Medicare ID - Type Unspecified