Provider Demographics
NPI:1578765400
Name:DR. NICOLE L. BLUST, LLC
Entity Type:Organization
Organization Name:DR. NICOLE L. BLUST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLUST
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:513-313-9412
Mailing Address - Street 1:7755 PARAGON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4055
Mailing Address - Country:US
Mailing Address - Phone:937-567-7800
Mailing Address - Fax:937-567-7808
Practice Address - Street 1:7755 PARAGON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4055
Practice Address - Country:US
Practice Address - Phone:937-567-7800
Practice Address - Fax:937-567-7808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6309103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty