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General NPI Number Information
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NPI Number | 1891920757
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Entity Type | Organization
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Legal Business Name | BLOUNT PSYCHOLOGY INCORPORATED
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Dates
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Enumeration Date | 05/21/2009
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Last Update Date | 10/13/2014
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Provider Practice Location Address
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Address Line | 1604 CHICAGO AVE STE.10
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City | EVANSTON
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State | IL
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Zip | 60201-6017
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Country | US
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Telephone | 773-633-0116
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Fax |
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Provider Business Mailing Address
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Address Line | 729 EMERSON ST APT.2E
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City | EVANSTON
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State | IL
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Zip | 60201-3836
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Country | US
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Telephone | 773-633-0116
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Fax |
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Authorized Official
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Title or Position | DIRECTOR/CLINICAL PSYCHOLOGIST
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Name | DR. MELISSA RUTH BLOUNT
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Credential | PH.D.
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Telephone | 773-633-0116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071007335
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License Number State | IL
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