Provider Demographics
NPI:1568065720
Name:BLAIR, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:MATLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:721 STEDMAN ST
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-6632
Mailing Address - Country:US
Mailing Address - Phone:907-225-7825
Mailing Address - Fax:907-225-1541
Practice Address - Street 1:LOT 3C BLOCK 5 GOOSE CREEK
Practice Address - Street 2:
Practice Address - City:THORNE BAY
Practice Address - State:AK
Practice Address - Zip Code:99919
Practice Address - Country:US
Practice Address - Phone:907-205-7596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health