Provider Demographics
NPI:1063541308
Name:BLUMTHAL, DEBRA LOUISE (NCC, LCPC)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:LOUISE
Last Name:BLUMTHAL
Suffix:
Gender:F
Credentials:NCC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3838
Mailing Address - Country:US
Mailing Address - Phone:217-744-3525
Mailing Address - Fax:217-744-2525
Practice Address - Street 1:215 S GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3838
Practice Address - Country:US
Practice Address - Phone:217-744-3525
Practice Address - Fax:217-744-2525
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006218101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.006218OtherSTATE LICENSE NUMBER-LCPC