Provider Demographics
NPI:1225099047
Name:BLOOM, STEPHANIE R (OTR CHT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:BLOOM
Suffix:
Gender:F
Credentials:OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9404 GENESEE AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-455-1195
Mailing Address - Fax:858-455-7101
Practice Address - Street 1:9404 GENESEE AVE
Practice Address - Street 2:STE 310
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-455-1195
Practice Address - Fax:858-455-7101
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT598/9105000125225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17215AMedicare PIN
CACB225322Medicare PIN