Healthcare Provider Details

I. General information

NPI: 1962912337
Provider Name (Legal Business Name): BLAIR MINNIS LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2806 GOLDSPRING LN
SPRING TX
77373-5870
US

IV. Provider business mailing address

2806 GOLDSPRING LN
SPRING TX
77373-5870
US

V. Phone/Fax

Practice location:
  • Phone: 855-862-3278
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12760
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: