Provider Demographics
NPI:1831112861
Name:BLAIN, SUSAN W (PSY D)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:W
Last Name:BLAIN
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6651 CHIPPEWA
Mailing Address - Street 2:STE 223
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2531
Mailing Address - Country:US
Mailing Address - Phone:314-644-2395
Mailing Address - Fax:314-644-5917
Practice Address - Street 1:6651 CHIPPEWA
Practice Address - Street 2:STE 223
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2531
Practice Address - Country:US
Practice Address - Phone:314-644-2395
Practice Address - Fax:314-644-5917
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S21684OtherMARCY HMO
3894OtherBLUE CROSS
6156413OtherBLUE CROSS HARMONY