Provider Demographics
NPI:1497277594
Name:BLOM, CHELSEA RAE
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:RAE
Last Name:BLOM
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 1:16347 MATEO ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-3129
Mailing Address - Country:US
Mailing Address - Phone:510-909-2430
Mailing Address - Fax:
Practice Address - Street 1:16347 MATEO ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-3129
Practice Address - Country:US
Practice Address - Phone:510-909-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000296622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty