Provider Demographics
NPI:1477702884
Name:SHERRY BLAIR INSTITUTE FOR INSPIRATIONAL CHANGE, LLC
Entity Type:Organization
Organization Name:SHERRY BLAIR INSTITUTE FOR INSPIRATIONAL CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, BCPC
Authorized Official - Phone:973-746-0333
Mailing Address - Street 1:216 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2926
Mailing Address - Country:US
Mailing Address - Phone:973-943-6356
Mailing Address - Fax:
Practice Address - Street 1:80 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042
Practice Address - Country:US
Practice Address - Phone:973-746-0333
Practice Address - Fax:973-746-1533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0032484Medicaid