Provider Demographics
NPI:1487862041
Name:BLAIR, SHIRLEY JOANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:JOANNE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95456-0376
Mailing Address - Country:US
Mailing Address - Phone:707-937-3992
Mailing Address - Fax:
Practice Address - Street 1:33200 FROG POND ROAD
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:CA
Practice Address - Zip Code:95456
Practice Address - Country:US
Practice Address - Phone:707-972-2048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21383103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical