Provider Demographics
NPI:1972737609
Name:BLUMBERG, MICHAEL (MA, LCPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:BLUMBERG
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 N NORTHWEST HWY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1444
Mailing Address - Country:US
Mailing Address - Phone:847-299-3400
Mailing Address - Fax:847-299-3487
Practice Address - Street 1:1580 N NORTHWEST HWY
Practice Address - Street 2:SUITE 215
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1444
Practice Address - Country:US
Practice Address - Phone:847-299-3400
Practice Address - Fax:847-299-3487
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-09
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007166101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional