Provider Demographics
NPI:1639485204
Name:BLUM, CAROLYN NICOLE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:NICOLE
Last Name:BLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 KEANU ST
Mailing Address - Street 2:#2
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-5580
Mailing Address - Country:US
Mailing Address - Phone:609-351-2983
Mailing Address - Fax:
Practice Address - Street 1:4132 KEANU ST.
Practice Address - Street 2:#2
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-5580
Practice Address - Country:US
Practice Address - Phone:609-351-2983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1170471101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool