Provider Demographics
NPI:1124241492
Name:MCCRACKEN, BLAIR (PHD)
Entity type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-1870
Mailing Address - Country:US
Mailing Address - Phone:203-457-0696
Mailing Address - Fax:203-457-9005
Practice Address - Street 1:42 LONG HILL RD
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-1870
Practice Address - Country:US
Practice Address - Phone:203-457-0696
Practice Address - Fax:203-457-9005
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002583103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical