MEDICARE: BLAIR COUNSELING SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5193719565	OTHER		PECOS I.D.
2	22267	OTHER	NY	LICENSE NUMBER

General Provider Information

NPI Number	:	1275251217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAIR COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	2112 ERIE BLVD E
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13224-1041
Country	:	US
Telephone Number	:	315-813-7062
Fax Number	:	315-813-7067

Provider Business Practice Location Address
First Line	:	2112 ERIE BLVD E
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13224-1041
Country	:	US
Telephone Number	:	315-813-7062
Fax Number	:	315-813-7067

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DAVID ALLEN BLAIR
Credential	:	LCSW-R
Telephone Number	:	315-813-7062

Provider Enumeration Date	:	08/16/2022
Last Update Date	:	08/16/2022

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