Provider Demographics
NPI:1376318014
Name:ROSENBLOOM, MITCHELL L (CHW)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:L
Last Name:ROSENBLOOM
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 104TH LN NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-1516
Mailing Address - Country:US
Mailing Address - Phone:612-964-2448
Mailing Address - Fax:
Practice Address - Street 1:349 104TH LN NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-1516
Practice Address - Country:US
Practice Address - Phone:612-964-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker