Basic Information
Provider Information | |||||||||
NPI: | 1811308836 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLUM | ||||||||
FirstName: | AINSLEY | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC, SAC-IT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VANDYCK | ||||||||
OtherFirstName: | AINSLEY | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC, SAC-IT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22040 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543052040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204457226 | ||||||||
FaxNumber: | 9204457229 | ||||||||
Practice Location | |||||||||
Address1: | 301 E SAINT JOSEPH ST | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543012241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204336073 | ||||||||
FaxNumber: | 9204310333 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2014 | ||||||||
LastUpdateDate: | 11/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 1951-226 | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 17069-130 | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X |   | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X |   | WI | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 101YP2500X | 5863-125 | WI | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 100037900 | 05 | WI |   | MEDICAID |