Provider Demographics
NPI:1477110500
Name:DIDIO, BLAIR (LAC)
Entity Type:Individual
Prefix:MRS
First Name:BLAIR
Middle Name:
Last Name:DIDIO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-2820
Mailing Address - Country:US
Mailing Address - Phone:732-540-4197
Mailing Address - Fax:
Practice Address - Street 1:166 MAIN ST
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-3104
Practice Address - Country:US
Practice Address - Phone:732-290-9040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00321200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health