Provider Demographics
NPI:1982005187
Name:BLAIR, IAN DAVID JR
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:DAVID
Last Name:BLAIR
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3418
Mailing Address - Country:US
Mailing Address - Phone:800-261-8850
Mailing Address - Fax:269-968-2651
Practice Address - Street 1:151 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3418
Practice Address - Country:US
Practice Address - Phone:800-261-8850
Practice Address - Fax:269-968-2651
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010916091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical