Provider Demographics
NPI:1750605556
Name:BLAINE, DOUGLAS J SR (MS, LPC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:BLAINE
Suffix:SR
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1242 W CHESTER PIKE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-5657
Mailing Address - Country:US
Mailing Address - Phone:484-266-0084
Mailing Address - Fax:484-266-0103
Practice Address - Street 1:1242 W CHESTER PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-5657
Practice Address - Country:US
Practice Address - Phone:484-266-0084
Practice Address - Fax:484-266-0103
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAPC007918101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional