Provider Demographics
NPI:1366607012
Name:BLAIR, CASSIDY F (PSYD)
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:F
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9454 WILSHIRE BLVD
Mailing Address - Street 2:PH 6
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-2937
Mailing Address - Country:US
Mailing Address - Phone:310-866-6414
Mailing Address - Fax:310-826-4706
Practice Address - Street 1:12021 WILSHIRE BLVD
Practice Address - Street 2:SUITE 430
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1206
Practice Address - Country:US
Practice Address - Phone:310-866-6414
Practice Address - Fax:310-826-4706
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22022103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist