Provider Demographics
NPI:1437217874
Name:BLOSSOM, CHERYL LYNNE (MSW)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNNE
Last Name:BLOSSOM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:BELL
Other - Last Name:SILAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:3409-D LAFAYETTE DR. NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107
Mailing Address - Country:US
Mailing Address - Phone:505-250-6723
Mailing Address - Fax:
Practice Address - Street 1:2420 JUAN TABO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1818
Practice Address - Country:US
Practice Address - Phone:505-292-2237
Practice Address - Fax:505-830-6527
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-34951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51786826Medicaid