Provider Demographics
NPI:1831657956
Name:BLUNTLY COACHED, LLC
Entity Type:Organization
Organization Name:BLUNTLY COACHED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GANIYAT
Authorized Official - Middle Name:
Authorized Official - Last Name:BADMUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-754-2164
Mailing Address - Street 1:11779 SOMERSET AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:PRINCESS ANNE
Mailing Address - State:MD
Mailing Address - Zip Code:21853-1271
Mailing Address - Country:US
Mailing Address - Phone:443-754-2164
Mailing Address - Fax:866-993-1076
Practice Address - Street 1:11779 SOMERSET AVE STE 12
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-1271
Practice Address - Country:US
Practice Address - Phone:443-754-2164
Practice Address - Fax:866-993-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD302168800Medicaid