Provider Demographics
NPI:1659444990
Name:WILES, BLAIR (MA)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:WILES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E 8TH AVE UNIT 202
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5797
Mailing Address - Country:US
Mailing Address - Phone:970-247-9228
Mailing Address - Fax:
Practice Address - Street 1:315 E 8TH AVE UNIT 202
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5797
Practice Address - Country:US
Practice Address - Phone:970-247-9228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2279101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health