Provider Demographics
NPI:1780904185
Name:BLAIN, DONNA MARIE (MA, CCC-A)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MARIE
Last Name:BLAIN
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1264
Mailing Address - Country:US
Mailing Address - Phone:860-557-2227
Mailing Address - Fax:860-570-2227
Practice Address - Street 1:139 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1264
Practice Address - Country:US
Practice Address - Phone:860-557-2227
Practice Address - Fax:860-570-2227
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000264231H00000X, 231HA2400X, 231HA2500X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004170726Medicaid