Provider Demographics
NPI:1891260402
Name:BLUM, LISA ROSE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ROSE
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 1:99 UNIVERSITY PL
Mailing Address - Street 2:FL 9
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4528
Mailing Address - Country:US
Mailing Address - Phone:212-604-1316
Mailing Address - Fax:212-604-1320
Practice Address - Street 1:99 UNIVERSITY PL
Practice Address - Street 2:FL 9
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4528
Practice Address - Country:US
Practice Address - Phone:212-604-1316
Practice Address - Fax:212-604-1320
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist