Healthcare Provider Details

I. General information

NPI: 1790609147
Provider Name (Legal Business Name): MISS EMILY ELIZABETH BLAIR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N CHURCH ST STE 1
MOORESTOWN NJ
08057-2493
US

IV. Provider business mailing address

132 POLK ST
RIVERSIDE NJ
08075-3137
US

V. Phone/Fax

Practice location:
  • Phone: 856-200-8203
  • Fax:
Mailing address:
  • Phone: 862-242-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37AC00991200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: