Provider Demographics
NPI:1972663920
Name:BLAIR, CAROL (LCSWR)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 EAST LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-2502
Mailing Address - Country:US
Mailing Address - Phone:516-799-5031
Mailing Address - Fax:516-799-8303
Practice Address - Street 1:92 EAST LAKE AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2502
Practice Address - Country:US
Practice Address - Phone:516-799-5031
Practice Address - Fax:516-799-8303
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR040861-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN9J981Medicare ID - Type Unspecified