Provider Demographics
NPI:1053971267
Name:BLUM, BONNIE LENNARD
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:LENNARD
Last Name:BLUM
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 1:12225 DOROTHY ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5220
Mailing Address - Country:US
Mailing Address - Phone:310-207-8480
Mailing Address - Fax:310-442-3610
Practice Address - Street 1:12225 DOROTHY ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5220
Practice Address - Country:US
Practice Address - Phone:310-207-8480
Practice Address - Fax:310-442-3610
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14531235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist