Provider Demographics
NPI:1629897178
Name:SHRUM, BLAINE MICHAEL (MSEDS)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:MICHAEL
Last Name:SHRUM
Suffix:
Gender:M
Credentials:MSEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 W BALTIMORE ST APT F
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:17225-1604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10435 DOWNSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-1732
Practice Address - Country:US
Practice Address - Phone:301-766-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD122033103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool