Provider Demographics
NPI:1518013192
Name:BLUMBERG, LOUIS MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:MICHAEL
Last Name:BLUMBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N. 8TH STRREET
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-9411
Mailing Address - Country:US
Mailing Address - Phone:760-482-4077
Mailing Address - Fax:
Practice Address - Street 1:202 N 8TH ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2402
Practice Address - Country:US
Practice Address - Phone:760-482-4087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5338103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR25897Medicare UPIN
CAWCP5338AMedicare PIN