=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154525194
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH SUSAN BLUMBERG PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2007
-----------------------------------------------------
Last Update Date | 10/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 2ND AVE BOSTON IVF - DOMAR CENTER FOR MIND/BODY HEALTH
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02451-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-434-6578
-----------------------------------------------------
Fax | 781-370-2330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 2ND AVE BOSTON IVF - DOMAR CENTER FOR MIND/BODY HEALTH
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02451-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-434-6578
-----------------------------------------------------
Fax | 781-370-2330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 5027
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------