Provider Demographics
NPI:1548326457
Name:BLUM, CAROL SUE (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:SUE
Last Name:BLUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 VISTA DEL REINO
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-8920
Mailing Address - Country:US
Mailing Address - Phone:406-381-0645
Mailing Address - Fax:
Practice Address - Street 1:6610 VISTA DEL REINO
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-8920
Practice Address - Country:US
Practice Address - Phone:575-556-9493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1476103TC0700X
HI1486103TC0700X
MT257103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT492921Medicaid
MT490165Medicaid
MT50771OtherBCBS
MT50771OtherBCBS
MT5506Medicare ID - Type Unspecified