MEDICARE: DR. SHIRLEY JOANNE BLAIR PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY21383	CA

General Provider Information

NPI Number	:	1487862041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHIRLEY JOANNE BLAIR PSY.D.

Provider Business Mailing Address
First Line	:	PO BOX 376
Second Line	:
City	:	LITTLE RIVER
State	:	CA
Zip	:	95456-0376
Country	:	US
Telephone Number	:	707-937-3992
Fax Number	:

Provider Business Practice Location Address
First Line	:	33200 FROG POND ROAD
Second Line	:
City	:	LITTLE RIVER
State	:	CA
Zip	:	95456
Country	:	US
Telephone Number	:	707-972-2048
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	07/08/2007

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