MEDICARE: DR. NICOLE L. BLUST, LLC

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	103T00000X	Psychologist	6309	OH

General Provider Information

NPI Number	:	1578765400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. NICOLE L. BLUST, LLC

Provider Business Mailing Address
First Line	:	7755 PARAGON RD
Second Line	:	SUITE 102
City	:	DAYTON
State	:	OH
Zip	:	45459-4055
Country	:	US
Telephone Number	:	937-567-7800
Fax Number	:	937-567-7808

Provider Business Practice Location Address
First Line	:	7755 PARAGON RD
Second Line	:	SUITE 102
City	:	DAYTON
State	:	OH
Zip	:	45459-4055
Country	:	US
Telephone Number	:	937-567-7800
Fax Number	:	937-567-7808

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. NICOLE L BLUST
Credential	:	PSY.D.
Telephone Number	:	513-313-9412

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	03/11/2010

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