Healthcare Provider Details

I. General information

NPI: 1184837486
Provider Name (Legal Business Name): MARY BETH BLAIR LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 02/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 WHITESPORT CIR SW STE 2
HUNTSVILLE AL
35801-6443
US

IV. Provider business mailing address

5750A SOUTHLAND DR
MOBILE AL
36693-3316
US

V. Phone/Fax

Practice location:
  • Phone: 256-533-9393
  • Fax: 256-533-9690
Mailing address:
  • Phone: 251-450-5901
  • Fax: 251-662-7297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2567
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2567
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: