Provider Demographics
NPI:1043415599
Name:BLOOM, GWEN (LCSW)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 E JERSEY ST
Mailing Address - Street 2:DEPT. BEHAVIORAL HEALTH & PSYCHIATRY
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07206-1259
Mailing Address - Country:US
Mailing Address - Phone:908-994-5000
Mailing Address - Fax:908-994-5000
Practice Address - Street 1:3322 RTE 22 STE 428
Practice Address - Street 2:
Practice Address - City:BRANCHBURG
Practice Address - State:NJ
Practice Address - Zip Code:08876-3395
Practice Address - Country:US
Practice Address - Phone:732-501-5917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05137300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SC05137300OtherSTATE LICENSE