Provider Demographics
NPI:1013723212
Name:BLAIR, FAITH NICOLE
Entity type:Individual
Prefix:
First Name:FAITH
Middle Name:NICOLE
Last Name:BLAIR
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 1:4684 E STATE ROAD 201
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-9313
Mailing Address - Country:US
Mailing Address - Phone:260-438-5470
Mailing Address - Fax:
Practice Address - Street 1:201 E RUDISILL BLVD # B100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-1738
Practice Address - Country:US
Practice Address - Phone:260-255-3665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician