Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 464 | WV |
N | 103T00000X | Psychologist | 464 | WV |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 464 | WV |
Y | 103G00000X | Clinical Psychologist | 464 | WV |
Y | 103TC0700X | Clinical Psychologist | 464 | WV |
NPI | 1285794644 |
---|---|
Provider Name | David Richard Blum |
First Address | Weirton, WV 26062-5003 |
Second Address | Weirton, WV 26062-5003 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/12/2006 |
Last Update Date | 25/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001719066 | BCBS (01) | WV |
0165132000 | (05) | WV |