Provider Demographics
NPI:1841551835
Name:BLAISDELL, TALIA HOPE
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:HOPE
Last Name:BLAISDELL
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 1:120 MECHANIC ST STE B
Mailing Address - Street 2:
Mailing Address - City:UPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01568-1578
Mailing Address - Country:US
Mailing Address - Phone:508-922-9506
Mailing Address - Fax:
Practice Address - Street 1:39 MAIN ST
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462-1428
Practice Address - Country:US
Practice Address - Phone:978-956-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
MA2975103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No252Y00000XAgenciesEarly Intervention Provider Agency