Provider Demographics
NPI:1124816764
Name:BLUMENTHAL, THEODORE (MA)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:
Last Name:BLUMENTHAL
Suffix:
Gender:
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NH
Mailing Address - Zip Code:03275-1145
Mailing Address - Country:US
Mailing Address - Phone:301-706-3918
Mailing Address - Fax:
Practice Address - Street 1:99 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3852
Practice Address - Country:US
Practice Address - Phone:603-229-3985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health