Provider Demographics
NPI:1851790646
Name:BLAIS, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:BLAIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 LONG MEADOW FARM DR
Mailing Address - Street 2:
Mailing Address - City:EPPING
Mailing Address - State:NH
Mailing Address - Zip Code:03042-2910
Mailing Address - Country:US
Mailing Address - Phone:603-235-9429
Mailing Address - Fax:
Practice Address - Street 1:27 LONG MEADOW FARM DR
Practice Address - Street 2:
Practice Address - City:EPPING
Practice Address - State:NH
Practice Address - Zip Code:03042-2910
Practice Address - Country:US
Practice Address - Phone:603-235-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-12-11718103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst