Provider Demographics
NPI:1114418902
Name:BLOOM, ELLEN B
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8751 WHIPPOORWILL RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND
Mailing Address - State:OH
Mailing Address - Zip Code:44412-9708
Mailing Address - Country:US
Mailing Address - Phone:330-414-0382
Mailing Address - Fax:
Practice Address - Street 1:50 BLYMYER AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2343
Practice Address - Country:US
Practice Address - Phone:419-774-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist