Provider Demographics
NPI:1467224204
Name:BLAIR, CODY RYAN (MA, CADTP)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:RYAN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MA, CADTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 N GRAND AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4218
Mailing Address - Country:US
Mailing Address - Phone:714-477-4605
Mailing Address - Fax:
Practice Address - Street 1:902 N GRAND AVE STE 204
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4218
Practice Address - Country:US
Practice Address - Phone:918-282-2193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-25
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1376254755101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)