Healthcare Provider Details

I. General information

NPI: 1851805436
Provider Name (Legal Business Name): GLENN BLUMENSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2017
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N HIGGINS AVE STE 409
MISSOULA MT
59802-4433
US

IV. Provider business mailing address

603 S 3RD ST W APT 2
MISSOULA MT
59801-2538
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-2539
  • Fax: 406-329-5663
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-23420
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: