Provider Demographics
NPI:1295589273
Name:BLAISDELL, CHRISTIE MARIE (CBT)
Entity type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:MARIE
Last Name:BLAISDELL
Suffix:
Gender:F
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 SE KING RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9715
Mailing Address - Country:US
Mailing Address - Phone:360-731-3524
Mailing Address - Fax:
Practice Address - Street 1:1605 WOODRIDGE DR SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3818
Practice Address - Country:US
Practice Address - Phone:360-443-2399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61214154106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician