Provider Demographics
NPI:1497810683
Name:BLOOM, JUDITH F (LICSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:F
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 GROTTO AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5517
Mailing Address - Country:US
Mailing Address - Phone:401-450-5916
Mailing Address - Fax:860-510-0020
Practice Address - Street 1:20 RESEARCH PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-4214
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:860-510-0020
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW013441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
413409OtherBLUE CHIP
1021740OtherNHP GROUP NUMBER
31344-7OtherBLUE CROSS BLUE SHIELD
RIJB01344Medicaid