Provider Demographics
NPI:1588779417
Name:BLUMENTHAL, J. ANDREA (MSW)
Entity type:Individual
Prefix:MRS
First Name:J.
Middle Name:ANDREA
Last Name:BLUMENTHAL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:JANE
Other - Middle Name:ANN
Other - Last Name:IVERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:388 TYLER RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6136
Mailing Address - Country:US
Mailing Address - Phone:505-265-1711
Mailing Address - Fax:505-256-6414
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:505-256-6414
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI14491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical