Provider Demographics
NPI:1154322394
Name:BLOOM, LONNIE N (PT)
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:N
Last Name:BLOOM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N LAVENTURE RD
Mailing Address - Street 2:STE A
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-3901
Mailing Address - Country:US
Mailing Address - Phone:360-428-2700
Mailing Address - Fax:360-428-2701
Practice Address - Street 1:110 N LAVENTURE RD
Practice Address - Street 2:STE A
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-3901
Practice Address - Country:US
Practice Address - Phone:360-428-2700
Practice Address - Fax:360-428-2701
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007498225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7155104Medicaid
WAGAB06760Medicare PIN
WA7155104Medicaid