Basic Information
Provider Information | |||||||||
NPI: | 1609265958 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLAIR | ||||||||
FirstName: | CATHY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FITZGERALD | ||||||||
OtherFirstName: | CATHY | ||||||||
OtherMiddleName: | IRENE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSW,LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1630 WOODS CT | ||||||||
Address2: |   | ||||||||
City: | HOOD RIVER | ||||||||
State: | OR | ||||||||
PostalCode: | 970312911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9718043071 | ||||||||
FaxNumber: | 5413876347 | ||||||||
Practice Location | |||||||||
Address1: | 1108 JUNE ST | ||||||||
Address2: |   | ||||||||
City: | HOOD RIVER | ||||||||
State: | OR | ||||||||
PostalCode: | 970311513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413871944 | ||||||||
FaxNumber: | 5413876315 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2015 | ||||||||
LastUpdateDate: | 01/09/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L4725 | OR | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 2002007819 | MO | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.