Provider Demographics
NPI:1396468427
Name:GOLDBLUM, ELENA (MA)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:GOLDBLUM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 LEEDOM WAY # 50
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-2332
Mailing Address - Country:US
Mailing Address - Phone:267-566-6118
Mailing Address - Fax:
Practice Address - Street 1:444 S STATE ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1945
Practice Address - Country:US
Practice Address - Phone:267-755-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1093339624Medicaid