Provider Demographics
NPI:1649345745
Name:BLAIR, SUSAN B (LCMFT, CCDP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:B
Last Name:BLAIR
Suffix:
Gender:F
Credentials:LCMFT, CCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3628
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20885-3628
Mailing Address - Country:US
Mailing Address - Phone:240-273-4645
Mailing Address - Fax:301-865-3264
Practice Address - Street 1:349 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-5780
Practice Address - Country:US
Practice Address - Phone:240-273-4645
Practice Address - Fax:301-865-3264
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM463106H00000X
VA0717001254106H00000X
DC000148106H00000X
WV3106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235942Medicaid
DC024905300Medicaid