Provider Demographics
NPI:1396758843
Name:BLAIR, MARC G (LISW)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:G
Last Name:BLAIR
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 SCARBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4049
Mailing Address - Country:US
Mailing Address - Phone:216-371-8621
Mailing Address - Fax:
Practice Address - Street 1:6200 SOM CENTER RD
Practice Address - Street 2:SUITE D 20
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2944
Practice Address - Country:US
Practice Address - Phone:216-371-8621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI. 00008011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical