Provider Demographics
NPI:1508138942
Name:BLAIR, SUSAN B (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:BLAIR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-5912
Mailing Address - Country:US
Mailing Address - Phone:817-335-4041
Mailing Address - Fax:817-336-0201
Practice Address - Street 1:1424 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5912
Practice Address - Country:US
Practice Address - Phone:817-335-4041
Practice Address - Fax:817-336-0201
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04743106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist