Provider Demographics
NPI:1962570242
Name:BLAIR, MELISSA M (PHD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:M
Last Name:BLAIR
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 1:3005 JAMES AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2589
Mailing Address - Country:US
Mailing Address - Phone:612-227-2829
Mailing Address - Fax:612-377-7501
Practice Address - Street 1:3005 JAMES AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2533
Practice Address - Country:US
Practice Address - Phone:612-227-2829
Practice Address - Fax:612-377-7501
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3550103TC2200X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN040161700Medicaid
MN6173818OtherMEDICA OR UBH
MN117T6NA OR 114T7NAOtherBLUE CROSS BLUE SHIELD
MN20258-11OtherBHP
MN141774OtherUCARE