Provider Demographics
NPI:1659269512
Name:BLUMANTHAL, CONNOR JACOB
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:JACOB
Last Name:BLUMANTHAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MCDONALD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5950
Mailing Address - Country:US
Mailing Address - Phone:308-535-7140
Mailing Address - Fax:
Practice Address - Street 1:601 MCDONALD RD
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5950
Practice Address - Country:US
Practice Address - Phone:308-535-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool