Healthcare Provider Details

I. General information

NPI: 1922724087
Provider Name (Legal Business Name): DOUGLAS WILLIAM BLUME MA LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6692 SPRING ARBOR RD
JACKSON MI
49201-9322
US

IV. Provider business mailing address

2751 DEARING RD
SPRING ARBOR MI
49283-9781
US

V. Phone/Fax

Practice location:
  • Phone: 517-750-3869
  • Fax:
Mailing address:
  • Phone: 517-812-4527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451022582
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: