Provider Demographics
NPI:1891866943
Name:BLAIR, PHYLLIS A (PHD, LPCC)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:A
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PHD, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 ROMERO ST
Mailing Address - Street 2:#7
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-7302
Mailing Address - Country:US
Mailing Address - Phone:505-820-7515
Mailing Address - Fax:
Practice Address - Street 1:HWY 554 GATE 110
Practice Address - Street 2:
Practice Address - City:ABIQUIU
Practice Address - State:NM
Practice Address - Zip Code:87510-0631
Practice Address - Country:US
Practice Address - Phone:505-685-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM LPCC 2380101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00N776OtherBLUE CROSS BLUE SHIELD