Provider Demographics
NPI:1649317231
Name:BLAIR, SHANNON L (MS)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:L
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 N 82ND ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-5611
Mailing Address - Country:US
Mailing Address - Phone:408-484-3100
Mailing Address - Fax:408-484-3101
Practice Address - Street 1:6320 N 82ND ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-5611
Practice Address - Country:US
Practice Address - Phone:408-484-3100
Practice Address - Fax:408-484-3101
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ625840OtherAHCCCS PROVIDER NUMBER