Provider Demographics
NPI:1619017894
Name:BLAIR, MICHAEL RAY (LCSW, LPCC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:BLAIR
Suffix:
Gender:M
Credentials:LCSW, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5116 STONE MOUNTAIN RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3531
Mailing Address - Country:US
Mailing Address - Phone:505-792-1531
Mailing Address - Fax:
Practice Address - Street 1:4400 PRESIDENTIAL PL NE
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3442
Practice Address - Country:US
Practice Address - Phone:505-345-3046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0064101Y00000X
CO991350101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor