Provider Demographics
NPI:1255193017
Name:BLAIR, CAITLIN
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
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 1:814 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476
Mailing Address - Country:US
Mailing Address - Phone:707-509-8031
Mailing Address - Fax:707-339-8339
Practice Address - Street 1:814 BROADWAY
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476
Practice Address - Country:US
Practice Address - Phone:707-509-8031
Practice Address - Fax:707-339-8339
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1038741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86-1660470Medicaid
CA1205426905Medicaid