Provider Demographics
NPI:1437337870
Name:BLOOMFIELD, AMY JO (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:BLOOMFIELD
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 1103
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-9731
Mailing Address - Country:US
Mailing Address - Phone:304-237-5196
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 1103
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-9731
Practice Address - Country:US
Practice Address - Phone:304-237-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0582235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0154596000Medicaid