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General NPI Number Information
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NPI Number | 1861412983
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Entity Type | Individual
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Provider Name | BLAIR MICHAEL ROBERTS LCSW
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Gender | Male
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2900 BRISTOL ST J-204
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City | COSTA MESA
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State | CA
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Zip | 92626-5981
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Country | US
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Telephone | 714-510-6104
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Fax |
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Provider Business Mailing Address
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Address Line | 137 S LOS TIMBRES ST
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City | ORANGE
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State | CA
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Zip | 92869-4200
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Country | US
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Telephone | 714-510-6104
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Fax | 714-538-6103
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCS14938
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License Number State | CA
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