MEDICARE: DIANE M BLUMLO M.S. DD & ABA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1285973495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE M BLUMLO M.S. DD & ABA

Provider Business Mailing Address
First Line	:	8 WINTERLING PL
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-7605
Country	:	US
Telephone Number	:	305-393-3324
Fax Number	:

Provider Business Practice Location Address
First Line	:	8 WINTERLING PL
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-7605
Country	:	US
Telephone Number	:	305-393-3324
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2013
Last Update Date	:	12/06/2016

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