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General NPI Number Information
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NPI Number | 1962941450
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Entity Type | Organization
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Legal Business Name | BLAIR WELLNESS GROUP A PROFESSIONAL PSYCHOLOGICAL CORP
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Dates
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Enumeration Date | 02/16/2017
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Last Update Date | 03/03/2017
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Provider Practice Location Address
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Address Line | 9454 WILSHIRE BLVD PH6
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City | BEVERLY HILLS
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State | CA
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Zip | 90212-2937
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Country | US
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Telephone | 310-866-6414
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Fax |
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Provider Business Mailing Address
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Address Line | 12021 WILSHIRE BLVD # 430
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City | LOS ANGELES
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State | CA
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Zip | 90025-1206
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Country | US
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Telephone | 310-866-6414
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CASSIBY F BLAIR
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Credential | PSYD
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Telephone | 310-866-6414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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