Provider Demographics
NPI:1962912337
Name:MINNIS, BLAIR (LCDC)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:MINNIS
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 GOLDSPRING LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77373-5870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2806 GOLDSPRING LN
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77373-5870
Practice Address - Country:US
Practice Address - Phone:855-862-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12760101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12760OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES