Provider Demographics
NPI:1063625481
Name:BLAIR, MICHAEL EVAN (LMFT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EVAN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 EAST 450 SOUTH
Mailing Address - Street 2:
Mailing Address - City:MANTI
Mailing Address - State:UT
Mailing Address - Zip Code:84642
Mailing Address - Country:US
Mailing Address - Phone:143-570-3075
Mailing Address - Fax:
Practice Address - Street 1:90 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:UT
Practice Address - Zip Code:84665
Practice Address - Country:US
Practice Address - Phone:435-703-0756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1157703902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist