Healthcare Provider Details

I. General information

NPI: 1568065720
Provider Name (Legal Business Name): TARA BLAIR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CRAIG KLAWOCK HWY # 241
CRAIG AK
99921-0678
US

IV. Provider business mailing address

721 STEDMAN ST
KETCHIKAN AK
99901-6632
US

V. Phone/Fax

Practice location:
  • Phone: 907-826-3891
  • Fax:
Mailing address:
  • Phone: 907-225-7825
  • Fax: 907-225-1541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: