Provider Demographics
NPI:1265864425
Name:BLOOMER, PHILIP (LCSW)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:BLOOMER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 20TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1850
Mailing Address - Country:US
Mailing Address - Phone:304-696-8700
Mailing Address - Fax:304-636-8701
Practice Address - Street 1:800 20TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1850
Practice Address - Country:US
Practice Address - Phone:304-696-8700
Practice Address - Fax:304-636-8701
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5152101YM0800X
WVDP009453551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid