Provider Demographics
NPI:1841442688
Name:BLAIR, CATHY JUNELLE
Entity type:Individual
Prefix:MRS
First Name:CATHY
Middle Name:JUNELLE
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 1:2012 READY AVE
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-2056
Mailing Address - Country:US
Mailing Address - Phone:810-744-0490
Mailing Address - Fax:
Practice Address - Street 1:2012 READY AVE
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-2056
Practice Address - Country:US
Practice Address - Phone:810-744-0490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF250272988171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor