Provider Demographics
NPI:1518061761
Name:BLUMBERG, STEPHEN R (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
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:PO BOX 243877
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33424-3877
Mailing Address - Country:US
Mailing Address - Phone:561-254-9434
Mailing Address - Fax:954-566-1186
Practice Address - Street 1:915 MIDDLE RIVER DR
Practice Address - Street 2:SUITE 307
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3544
Practice Address - Country:US
Practice Address - Phone:561-254-9434
Practice Address - Fax:954-566-1186
Is Sole Proprietor?:No
Enumeration Date:2006-09-09
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3334103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03416Medicare ID - Type Unspecified