Provider Demographics
NPI:1306483409
Name:BLYDENBURGH, CHRISTOPHER WILLIAM
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:WILLIAM
Last Name:BLYDENBURGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 E MARCO CT # 11
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:FL
Mailing Address - Zip Code:34442-2962
Mailing Address - Country:US
Mailing Address - Phone:352-270-5003
Mailing Address - Fax:
Practice Address - Street 1:2535 E MARCO CT # 11
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:FL
Practice Address - Zip Code:34442-2962
Practice Address - Country:US
Practice Address - Phone:352-270-5003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-08
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician