Provider Demographics
NPI:1164660551
Name:BLOOM, AMANDA (MED, NCC, LPC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MED, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 S MADISON BLVD
Mailing Address - Street 2:SUITE C1
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-5485
Mailing Address - Country:US
Mailing Address - Phone:336-599-8366
Mailing Address - Fax:336-322-6168
Practice Address - Street 1:355 S MADISON BLVD
Practice Address - Street 2:SUITE C1
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-5485
Practice Address - Country:US
Practice Address - Phone:336-599-8366
Practice Address - Fax:336-322-6168
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7282101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional