Healthcare Provider Details

I. General information

NPI: 1639485204
Provider Name (Legal Business Name): CAROLYN NICOLE BLUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4132 KEANU ST. #2
HONOLULU HI
96816-5580
US

IV. Provider business mailing address

4132 KEANU ST #2
HONOLULU HI
96816-5580
US

V. Phone/Fax

Practice location:
  • Phone: 609-351-2983
  • Fax:
Mailing address:
  • Phone: 609-351-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number1170471
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: