Healthcare Provider Details

I. General information

NPI: 1891711131
Provider Name (Legal Business Name): KELLY LANE BLAIR PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 W FOREST AVE
JACKSON TN
38301-3901
US

IV. Provider business mailing address

1804 HIGHWAY 45 BYP SUITE 604
JACKSON TN
38305-4436
US

V. Phone/Fax

Practice location:
  • Phone: 731-425-4930
  • Fax:
Mailing address:
  • Phone: 731-660-8759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1706
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number1706
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: