Provider Demographics
NPI:1871778787
Name:BLUMENTHAL, SAMUEL LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:LEE
Last Name:BLUMENTHAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6406 CARMEL RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-8061
Mailing Address - Country:US
Mailing Address - Phone:704-341-0084
Mailing Address - Fax:704-544-8833
Practice Address - Street 1:6406 CARMEL RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8061
Practice Address - Country:US
Practice Address - Phone:704-341-0084
Practice Address - Fax:704-544-8833
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0962103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2814377Medicare PIN