Provider Demographics
NPI:1699581330
Name:BLAIR, IAN DAVIS
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:DAVIS
Last Name:BLAIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 ARCHER WAY
Mailing Address - Street 2:
Mailing Address - City:BEN LOMOND
Mailing Address - State:CA
Mailing Address - Zip Code:95005-9530
Mailing Address - Country:US
Mailing Address - Phone:831-334-4964
Mailing Address - Fax:
Practice Address - Street 1:10090 HIGHWAY 9 STE 6
Practice Address - Street 2:
Practice Address - City:BEN LOMOND
Practice Address - State:CA
Practice Address - Zip Code:95005-9251
Practice Address - Country:US
Practice Address - Phone:831-704-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-07
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15411101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor