Healthcare Provider Details

I. General information

NPI: 1689637175
Provider Name (Legal Business Name): BETSY KAREN BLUM LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETSY BLUM JACOBS

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 N 50TH ST
TAMPA FL
33610
US

IV. Provider business mailing address

190 112TH AVE N APT 1602
ST PETERSBURG FL
33716
US

V. Phone/Fax

Practice location:
  • Phone: 813-621-8781
  • Fax:
Mailing address:
  • Phone: 520-664-7820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068-0000546
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPMH1591
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: