Provider Demographics
NPI:1104199835
Name:BLOOMQUIST, CAROL DIANE (MA MFT)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:DIANE
Last Name:BLOOMQUIST
Suffix:
Gender:F
Credentials:MA MFT
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 403
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-0403
Mailing Address - Country:US
Mailing Address - Phone:707-963-1419
Mailing Address - Fax:707-963-0841
Practice Address - Street 1:3428 SILVERADO TRL N
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9662
Practice Address - Country:US
Practice Address - Phone:707-963-1419
Practice Address - Fax:707-963-0841
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 24307106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist