Provider Demographics
NPI:1003146853
Name:BLOOM, ADA M (LISW)
Entity Type:Individual
Prefix:MS
First Name:ADA
Middle Name:M
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:MICKIE
Other - Middle Name:
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW
Mailing Address - Street 1:1925 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4737
Mailing Address - Country:US
Mailing Address - Phone:419-557-5177
Mailing Address - Fax:419-557-5179
Practice Address - Street 1:1925 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4737
Practice Address - Country:US
Practice Address - Phone:419-557-5177
Practice Address - Fax:419-557-5179
Is Sole Proprietor?:No
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI98491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical