Provider Demographics
NPI:1932977121
Name:BLUNDELL, DESIRAY MARIE
Entity type:Individual
Prefix:
First Name:DESIRAY
Middle Name:MARIE
Last Name:BLUNDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 HARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BROWN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48416-8633
Mailing Address - Country:US
Mailing Address - Phone:810-276-1220
Mailing Address - Fax:
Practice Address - Street 1:8032 LAKESHORE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MI
Practice Address - Zip Code:48450-9719
Practice Address - Country:US
Practice Address - Phone:810-625-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst