Provider Demographics
NPI:1063002434
Name:BLUM, DEBRA MICHELLE
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:MICHELLE
Last Name:BLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45926 N 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85087-7022
Mailing Address - Country:US
Mailing Address - Phone:025-570-5514
Mailing Address - Fax:
Practice Address - Street 1:17505 N 79TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8725
Practice Address - Country:US
Practice Address - Phone:623-800-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-18959101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health