Provider Demographics
NPI:1629475132
Name:BLUMBERG, BEVERLY G (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:G
Last Name:BLUMBERG
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 COVE TOWER DR
Mailing Address - Street 2:#502
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-6031
Mailing Address - Country:US
Mailing Address - Phone:610-405-6001
Mailing Address - Fax:239-643-5908
Practice Address - Street 1:420 COVE TOWER DR
Practice Address - Street 2:#502
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-6031
Practice Address - Country:US
Practice Address - Phone:610-405-6001
Practice Address - Fax:239-643-5908
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12820235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013627300Medicaid