Provider Demographics
NPI:1154961886
Name:BLAIS, NICOL (LMHC)
Entity type:Individual
Prefix:
First Name:NICOL
Middle Name:
Last Name:BLAIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HIDALGO CT
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-8898
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1264 RODEO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6816
Practice Address - Country:US
Practice Address - Phone:505-982-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0207491101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor