Provider Demographics
NPI:1326536186
Name:BLOOM, REBECCA (LAC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 FOOTHILL RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2255
Mailing Address - Country:US
Mailing Address - Phone:973-994-1011
Mailing Address - Fax:
Practice Address - Street 1:1501 HAMBURG TPKE FL 4
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-4032
Practice Address - Country:US
Practice Address - Phone:908-585-1662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00826900101YP2500X
NJ37AC00404600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health