Provider Demographics
NPI:1326073578
Name:BLOOM, KATHARINE DUGAN (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:KATHARINE
Middle Name:DUGAN
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-1025
Mailing Address - Country:US
Mailing Address - Phone:207-799-1920
Mailing Address - Fax:207-774-7356
Practice Address - Street 1:222 SAINT JOHN ST
Practice Address - Street 2:SUITE 232
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3041
Practice Address - Country:US
Practice Address - Phone:207-756-5093
Practice Address - Fax:207-774-7356
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2270101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME294300099OtherMAINECARE