Provider Demographics
NPI:1083378400
Name:BLOOM, MAGDALENA ELYSE (LGSW)
Entity Type:Individual
Prefix:
First Name:MAGDALENA
Middle Name:ELYSE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10405 WINDROSE CURV
Mailing Address - Street 2:
Mailing Address - City:ELKO NEW MARKET
Mailing Address - State:MN
Mailing Address - Zip Code:55020-8522
Mailing Address - Country:US
Mailing Address - Phone:920-737-2281
Mailing Address - Fax:
Practice Address - Street 1:1201 HARMON PL
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2043
Practice Address - Country:US
Practice Address - Phone:612-313-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical