Provider Demographics
NPI:1427791128
Name:BLOME, BETTY J (MSW/LCSW)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:J
Last Name:BLOME
Suffix:
Gender:F
Credentials:MSW/LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 WHITEHALL RD APT A
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3776
Mailing Address - Country:US
Mailing Address - Phone:573-465-1040
Mailing Address - Fax:
Practice Address - Street 1:1510 WHITEHALL RD APT A
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3776
Practice Address - Country:US
Practice Address - Phone:573-465-1040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0046431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical