Provider Demographics
NPI:1639443716
Name:BLOUNT, IDA D (MS; LMFT)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:D
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:MS; LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24431 WOODSAGE DR
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7960
Mailing Address - Country:US
Mailing Address - Phone:239-992-2136
Mailing Address - Fax:
Practice Address - Street 1:24431 WOODSAGE DR
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7960
Practice Address - Country:US
Practice Address - Phone:239-992-2136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMFT381106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist