Provider Demographics
NPI:1053506147
Name:BLUM, FREDERICK M (MFT, PHD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:M
Last Name:BLUM
Suffix:
Gender:M
Credentials:MFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320-1634
Mailing Address - Country:US
Mailing Address - Phone:951-533-7467
Mailing Address - Fax:
Practice Address - Street 1:16955 LEMON ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-5139
Practice Address - Country:US
Practice Address - Phone:760-947-8223
Practice Address - Fax:760-947-8225
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 23846106H00000X
CAPSY23388103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist