Provider Demographics
NPI:1992927941
Name:BLOMQUIST, MARLYS (PHD)
Entity type:Individual
Prefix:
First Name:MARLYS
Middle Name:
Last Name:BLOMQUIST
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3468
Mailing Address - Street 2:POJOAQUE STATION
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-0468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PVS - 1574 ST. RD. 502
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501
Practice Address - Country:US
Practice Address - Phone:505-455-0801
Practice Address - Fax:505-455-3023
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM315117103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3581861Medicaid