Provider Demographics
NPI:1063131175
Name:BLUM, DAVID C (MBA, SUDPT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:BLUM
Suffix:
Gender:M
Credentials:MBA, SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 59
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0059
Mailing Address - Country:US
Mailing Address - Phone:360-740-4380
Mailing Address - Fax:360-740-1877
Practice Address - Street 1:1956 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2307
Practice Address - Country:US
Practice Address - Phone:360-740-4380
Practice Address - Fax:360-740-1877
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61337108101Y00000X
WACP61557487101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor