Basic Information
| Provider Information | |||||||||
| NPI: | 1134582612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUMENFELD | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 RODEO PARK DR W | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875056351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059869633 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2960 RODEO PARK DR W | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875056351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059869633 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2016 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | CCMH0207031 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106S00000X | N | 101YP2500X | CCMH0207031 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1134582612 | 05 | NM | MEDICAID |