Provider Demographics
NPI:1164268470
Name:BLUME, SOPHIA MARIE
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:MARIE
Last Name:BLUME
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 1:3805 LONG LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-4057
Mailing Address - Country:US
Mailing Address - Phone:360-529-9312
Mailing Address - Fax:
Practice Address - Street 1:3231 WILLAMETTE DR NE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-1378
Practice Address - Country:US
Practice Address - Phone:360-878-6434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61557311106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician