Provider Demographics
NPI:1073824991
Name:BLOOM COUNSELING, PC
Entity Type:Organization
Organization Name:BLOOM COUNSELING, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:W
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-222-7023
Mailing Address - Street 1:3113 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-9118
Mailing Address - Country:US
Mailing Address - Phone:580-222-7023
Mailing Address - Fax:
Practice Address - Street 1:3113 WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-9118
Practice Address - Country:US
Practice Address - Phone:580-222-7023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4312101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty