Provider Demographics
NPI:1356492110
Name:BLOOMQUIST, SHELLEY
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:BLOOMQUIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6083 BIG TREE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14487-9752
Mailing Address - Country:US
Mailing Address - Phone:585-346-6664
Mailing Address - Fax:
Practice Address - Street 1:400 NORTH MAIN ST.
Practice Address - Street 2:WYOMING COUNTY COMMUNITY HOSPITAL
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14469
Practice Address - Country:US
Practice Address - Phone:585-786-2233
Practice Address - Fax:585-786-1275
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003619-1225200000X
NY022063-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist