Provider Demographics
NPI:1437301710
Name:BLOOM, TINA (PHD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 AURORA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1123
Mailing Address - Country:US
Mailing Address - Phone:814-227-6376
Mailing Address - Fax:
Practice Address - Street 1:3512 QUENTIN RD SUITE 110 CHE SERVICES
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:855-688-6746
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC - 004932101YP2500X
NY020552-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPC - 004932OtherLICENSED PROFESSIONAL COUNSELOR