Provider Demographics
NPI:1043975881
Name:BLOOM, MICHAEL KAJ (BCBA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KAJ
Last Name:BLOOM
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3149
Mailing Address - Country:US
Mailing Address - Phone:203-271-1430
Mailing Address - Fax:
Practice Address - Street 1:673 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3149
Practice Address - Country:US
Practice Address - Phone:203-271-1430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1281103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst