Provider Demographics
NPI:1811537582
Name:BLUME, MARISA J (LAC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:J
Last Name:BLUME
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:918 HERMES AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1701
Mailing Address - Country:US
Mailing Address - Phone:805-901-7670
Mailing Address - Fax:
Practice Address - Street 1:4405 MANCHESTER AVE STE 208
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-7902
Practice Address - Country:US
Practice Address - Phone:760-456-5343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18789171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18789OtherLICENSE NUMBER