Provider Demographics
NPI:1073859211
Name:BLUMENTHAL, MICHELLE ROSE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ROSE
Last Name:BLUMENTHAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N WASHINGTON ST # 300-31
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-2223
Mailing Address - Country:US
Mailing Address - Phone:301-941-7838
Mailing Address - Fax:
Practice Address - Street 1:110 N WASHINGTON ST # 300-31
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-2223
Practice Address - Country:US
Practice Address - Phone:301-941-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05649103TC0700X
VA0810004666103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent