Provider Demographics
NPI:1164493169
Name:BLUM, LESLIE S (LCSW-C, BCD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:S
Last Name:BLUM
Suffix:
Gender:F
Credentials:LCSW-C, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 TERRAPIN RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-3128
Mailing Address - Country:US
Mailing Address - Phone:410-486-3440
Mailing Address - Fax:410-363-1612
Practice Address - Street 1:3411 TERRAPIN RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-3128
Practice Address - Country:US
Practice Address - Phone:410-486-3440
Practice Address - Fax:410-363-1612
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06471101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPV40OtherMAGELLAN
MD074670OtherVALUEOPTIONS..MD /VA
MD074670OtherVALUEOPTIONS..MD /VA
MDY45414Medicare UPIN