MEDICARE: NELLY RICO BLUSTAJN LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	160258	CA

General Provider Information

NPI Number	:	1386501310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NELLY RICO BLUSTAJN LMFT

Provider Business Mailing Address
First Line	:	1047 LINCOLN BLVD APT 10
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4066
Country	:	US
Telephone Number	:	213-448-7799
Fax Number	:

Provider Business Practice Location Address
First Line	:	1047 LINCOLN BLVD APT 10
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4066
Country	:	US
Telephone Number	:	213-448-7799
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2026
Last Update Date	:	01/09/2026

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