Provider Demographics
NPI:1285794644
Name:BLUM, DAVID RICHARD (MA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RICHARD
Last Name:BLUM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 COLLIERS WAY
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5003
Mailing Address - Country:US
Mailing Address - Phone:304-723-5440
Mailing Address - Fax:
Practice Address - Street 1:501 COLLIERS WAY
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5003
Practice Address - Country:US
Practice Address - Phone:304-723-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV464103T00000X, 103TC0700X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001719066OtherBCBS
WV0165132000Medicaid