Provider Demographics
NPI:1053699942
Name:BLUMBERG, HEATHER AMANDA (LCSW)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:AMANDA
Last Name:BLUMBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N GARTH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4103
Mailing Address - Country:US
Mailing Address - Phone:573-449-2581
Mailing Address - Fax:573-449-2583
Practice Address - Street 1:117 N GARTH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4103
Practice Address - Country:US
Practice Address - Phone:573-449-2581
Practice Address - Fax:573-449-2583
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130310311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011008280OtherPROVISIONAL STATE LICENSE