Provider Demographics
NPI:1932477494
Name:BLUM, MATTHEW GREGG (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:GREGG
Last Name:BLUM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 SEAVIEW AVE
Mailing Address - Street 2:BUILDING #2
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3409
Mailing Address - Country:US
Mailing Address - Phone:718-351-5530
Mailing Address - Fax:718-351-5639
Practice Address - Street 1:777 SEAVIEW AVE
Practice Address - Street 2:BUILDING #2
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3409
Practice Address - Country:US
Practice Address - Phone:718-351-5530
Practice Address - Fax:718-351-5639
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13-4182492101Y00000X
NY058031-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker