Provider Demographics
NPI:1225214877
Name:WENDY BLUMENTHAL, PH.D.
Entity Type:Organization
Organization Name:WENDY BLUMENTHAL, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUMENTHAL, PH.D.
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:941-745-5111
Mailing Address - Street 1:3823 E STATE ROAD 64
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-9041
Mailing Address - Country:US
Mailing Address - Phone:941-745-5111
Mailing Address - Fax:941-745-5667
Practice Address - Street 1:3823 E STATE ROAD 64
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-9041
Practice Address - Country:US
Practice Address - Phone:941-745-5111
Practice Address - Fax:941-745-5667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9317261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
68BBGJTMedicare PIN
GA000415445AMedicaid