Provider Demographics
NPI:1134298458
Name:BLOOM, LINDA (LCSW)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 WISSAHICKON AVE
Mailing Address - Street 2:E301
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4554
Mailing Address - Country:US
Mailing Address - Phone:215-848-7526
Mailing Address - Fax:
Practice Address - Street 1:5515 WISSAHICKON AVE
Practice Address - Street 2:E301
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-4554
Practice Address - Country:US
Practice Address - Phone:215-848-7526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0034851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA644677Medicare UPIN