Provider Demographics
NPI:1689637175
Name:BLUM, BETSY KAREN (LCMHC)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:KAREN
Last Name:BLUM
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:BLUM
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 112TH AVE N
Mailing Address - Street 2:APT 1602
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716
Mailing Address - Country:US
Mailing Address - Phone:520-664-7820
Mailing Address - Fax:
Practice Address - Street 1:3630 N 50TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610
Practice Address - Country:US
Practice Address - Phone:813-621-8781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000546101YM0800X
FLPMH1591101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008053Medicaid