Healthcare Provider Details

I. General information

NPI: 1780904185
Provider Name (Legal Business Name): DONNA MARIE BLAIN M.A., CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 N MAIN ST
WEST HARTFORD CT
06107-1264
US

IV. Provider business mailing address

139 N MAIN ST
WEST HARTFORD CT
06107-1264
US

V. Phone/Fax

Practice location:
  • Phone: 860-557-2227
  • Fax: 860-570-2227
Mailing address:
  • Phone: 860-557-2227
  • Fax: 860-570-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number000264
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number000264
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License Number000264
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number000264
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: