Healthcare Provider Details

I. General information

NPI: 1528033040
Provider Name (Legal Business Name): MARIDEANNE BLOMGREN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2006
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 ANDOVER DR
KENDALL PARK NJ
08824-7026
US

IV. Provider business mailing address

127 ANDOVER DR
KENDALL PARK NJ
08824-7026
US

V. Phone/Fax

Practice location:
  • Phone: 732-422-7669
  • Fax:
Mailing address:
  • Phone: 732-422-7669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC 00003200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: