Provider Demographics
NPI:1093134538
Name:BLOOM, COURTNEY (RD, LDN)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1111
Mailing Address - Street 2:
Mailing Address - City:HARLEYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19438-0907
Mailing Address - Country:US
Mailing Address - Phone:215-453-4995
Mailing Address - Fax:215-453-4646
Practice Address - Street 1:671 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARLEYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19438-1615
Practice Address - Country:US
Practice Address - Phone:215-453-3091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004770133V00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered