Provider Demographics
NPI:1811308836
Name:BLUM, AINSLEY E (LPC, SAC-IT)
Entity type:Individual
Prefix:
First Name:AINSLEY
Middle Name:E
Last Name:BLUM
Suffix:
Gender:F
Credentials:LPC, SAC-IT
Other - Prefix:
Other - First Name:AINSLEY
Other - Middle Name:E
Other - Last Name:VANDYCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, SAC-IT
Mailing Address - Street 1:PO BOX 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:301 E SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2241
Practice Address - Country:US
Practice Address - Phone:920-433-6073
Practice Address - Fax:920-431-0333
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16259101YA0400X
WI5863-125101YP2500X, 101YP2500X
WI101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100037900Medicaid