Healthcare Provider Details

I. General information

NPI: 1962383133
Provider Name (Legal Business Name): KELLEN BLUM M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W 14TH ST
INDIANAPOLIS IN
46202-2369
US

IV. Provider business mailing address

350 W 14TH ST
INDIANAPOLIS IN
46202-2369
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-6215
  • Fax:
Mailing address:
  • Phone: 317-274-6215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: