Healthcare Provider Details

I. General information

NPI: 1790315950
Provider Name (Legal Business Name): MICHELLE RAPHAEL BLUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2061 PEACHTREE RD NW #500, ATLANTA, GA 30309
ATLANTA GA
30309-1446
US

IV. Provider business mailing address

2061 PEACHTREE RD NW
ATLANTA GA
30309
US

V. Phone/Fax

Practice location:
  • Phone: 404-352-3522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT007601
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119009488
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT007601
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: