Provider Demographics
NPI:1326392531
Name:BLOOM, LAURA (LMSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23409 JEFFERSON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3449
Mailing Address - Country:US
Mailing Address - Phone:313-590-4740
Mailing Address - Fax:
Practice Address - Street 1:23409 JEFFERSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3449
Practice Address - Country:US
Practice Address - Phone:313-590-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2017-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010923451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical