Provider Demographics
NPI:1922692326
Name:BLOBAUM, AMY ANITA
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ANITA
Last Name:BLOBAUM
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 1:325 ILLINOIS RT 2
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-9118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W HAWLEY ST
Practice Address - Street 2:
Practice Address - City:AMBOY
Practice Address - State:IL
Practice Address - Zip Code:61310-1158
Practice Address - Country:US
Practice Address - Phone:815-246-8761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health