Provider Demographics
NPI:1629782073
Name:BLUMENBERG, NATHAN WILLIAM (LMSW)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:WILLIAM
Last Name:BLUMENBERG
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W 4TH S
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2319
Mailing Address - Country:US
Mailing Address - Phone:907-854-1972
Mailing Address - Fax:208-656-4018
Practice Address - Street 1:420 W 4TH S
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2319
Practice Address - Country:US
Practice Address - Phone:208-656-4017
Practice Address - Fax:208-656-4018
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID43020104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker