Provider Demographics
NPI:1407101199
Name:BLUME, STACY (MSED)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:BLUME
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 E 76TH ST
Mailing Address - Street 2:3B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-2517
Mailing Address - Country:US
Mailing Address - Phone:917-414-9695
Mailing Address - Fax:
Practice Address - Street 1:427 E 76TH ST
Practice Address - Street 2:3B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2517
Practice Address - Country:US
Practice Address - Phone:917-414-9695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1841103174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist