Provider Demographics
NPI:1730107228
Name:BLAIR, ELIZABETH MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
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 1:5900 N PORT WASHINGTON RD
Mailing Address - Street 2:STE 230
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-962-4048
Mailing Address - Fax:414-962-4052
Practice Address - Street 1:5900 N PORT WASHINGTON RD
Practice Address - Street 2:STE 230
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-962-4048
Practice Address - Fax:414-962-4052
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2121057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39125400Medicaid
WI39125400Medicaid
WI001344285Medicare ID - Type Unspecified