Provider Demographics
NPI:1215366075
Name:BLUME, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BLUME
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 1:5600 CAMERATA WAY UNIT 220
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5284
Mailing Address - Country:US
Mailing Address - Phone:612-616-4633
Mailing Address - Fax:
Practice Address - Street 1:2105 MINNEHAHA AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3107
Practice Address - Country:US
Practice Address - Phone:651-728-0745
Practice Address - Fax:612-333-5614
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN569101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health