Healthcare Provider Details

I. General information

NPI: 1649345745
Provider Name (Legal Business Name): SUSAN B. BLAIR LCMFT, CCDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 MAIN ST STE 1
GAITHERSBURG MD
20878-5780
US

IV. Provider business mailing address

PO BOX 3628
GAITHERSBURG MD
20885-3628
US

V. Phone/Fax

Practice location:
  • Phone: 240-273-4645
  • Fax: 301-865-3264
Mailing address:
  • Phone: 240-273-4645
  • Fax: 301-865-3264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLCM463
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001254
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000148
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: