Provider Demographics
NPI:1427778992
Name:BLAIR, AMANDA G
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:G
Last Name:BLAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 WILLOW OAKS CORPORATE DR STE 1-417
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4512
Mailing Address - Country:US
Mailing Address - Phone:703-559-3188
Mailing Address - Fax:
Practice Address - Street 1:8221 WILLOW OAKS CORPORATE DR STE 1-417
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4512
Practice Address - Country:US
Practice Address - Phone:703-559-3188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0732001055101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor